Two-step screening could prevent heart failure in diabetes with no history of CVD
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Key takeaways:
- Two-step screening may prevent incident HF in patients with diabetes and no CVD.
- Risk scoring followed by biomarker testing identified those who would most likely benefit from an SGLT2 inhibitor.
PHILADELPHIA — Early, cost-effective screening may predict and prevent incident heart failure events for patients with diabetes and no prior heart disease, a speaker reported.
Assessment using the WATCH-DM score followed by N-terminal pro-B-type natriuretic peptide testing successfully identified nearly 90% of patients with diabetes who could benefit from an SGLT2 inhibitor for the prevention of HF, according to a study presented at the Heart in Diabetes CME Conference session on cardiometabolic papers previously published in Circulation.
“The prevalence of diabetes is increasing worldwide and it is projected that by 2045 up to 700 million individuals in the world will have diabetes. ... Observations from epidemiological studies suggest that we need to do better when it comes to prevention of heart failure in diabetes,” Ambarish Pandey, MD, MSCS, associate professor in the department of internal medicine, division of cardiology and geriatrics and principal investigator in the cardiometabolic research unit at UT Southwestern Medical Center, said during a presentation. “Despite their promise, the uptake of SGLT2 inhibitors in individuals with type 2 diabetes has been slow and rather modest, even among those with other risk factors like [atherosclerotic] CVD, [chronic kidney disease] and heart failure. ... Thus, we need novel approaches to enhance utilization of effective heart failure therapies like SGLT2 inhibitors in patients with diabetes. One of the key strategies to improve the cost-efficient utilization of effective and expensive therapies such as SGLT2 inhibitors is use of a risk-based approach to target high-risk patients who are most likely to benefit from these therapies.”
Screening to prevent HF in diabetes
Pandey, Kershaw V. Patel, MD, MSCS, assistant professor of cardiology at Houston Methodist, Weill Cornell Medical College, and colleagues conducted the present pooled cohort analysis to evaluate optimal screening strategies to prevent HF development in adults with diabetes and no ASCVD or HF. Their analysis included data from seven community-based cohorts including the Atherosclerosis Risk in Communities study, Cardiovascular Health Study, Framingham offspring and third-generation cohorts, Multi-Ethnic Study of Atherosclerosis, Chronic Renal Insufficiency Cohort and the Prevention of Renal and Vascular End-Stage Disease study.
In a cohort of 6,293 participants (48% women; 77.7% without ASCVD), the researchers evaluated four one-step screening strategies: WATCH-DM risk score, NT-proBNP testing, high-sensitivity cardiac troponin testing and echocardiography-based diabetic cardiomyopathy testing.
At 5 years follow-up, 6.2% of participants without ASCVD experienced incident HF, with a number needed to treat to prevent one HF event with an SGLT2 inhibitor of 43 (95% CI, 29-72), according to the study.
Among one-step screening strategies, the WATCH-DM and echocardiographic assessment identified the most participants as being high risk for incident HF.
Among participants identified as low risk by the WATCH-DM risk score, NT-proBNP or high-sensitivity troponin screening, the number needed to treat to prevent one incident HF event with an SGLT2 inhibitor was at least twofold higher compared with the high-risk group. However, individuals without ASCVD identified as high risk for HF with one-step screening only accounted for 53% to 71% of HF events, indicating that up to 47% of events occurred in the population identified as low risk in one-step screening.
The researchers therefore tested two-step screening strategies to improve risk assessment for HF: WATCH-DM plus NT-proBNP, NT-proBNP plus high-sensitivity cardiac troponin and NT-proBNP plus echocardiography.
Improved screening in two steps
Two-step screening for HF risk in patients without ASCVD captured up to 89% of HF events in those identified as high risk, and subsequently the number needed to screen to prevent one HF event in a high-risk patient every 5 years was lower with two-step compared with one-step screening strategies (45 to 61 vs. 60 to 93), Pandey said.
The number needed to treat with an SGLT2 inhibitor to prevent one HF event in a high-risk patient every 5 years was 31 for the WATCH-DM plus NT-proBNP screening strategy, 30 for the NT-proBNP plus high-sensitivity cardiac troponin strategy and 32 for the NT-proBNP plus echocardiography strategy, he said.
Moreover, the WATCH-DM plus NT-proBNP screening strategy demonstrated the lowest number of screening tests needed to prevent one HF event — 27 tests — and conferred the lowest cost of screening in those initially identified as low-risk with one-step screening, at $1,061 per one HF event prevented compared with $2,894 for the NT-proBNP plus troponin strategy and $16,358 for the NT-proBNP plus echocardiography strategy.
“Among community-dwelling adults with diabetes who were free of cardiovascular disease, screening with the clinical risk score followed by cardiac biomarkers can efficiently identify individuals who are at a high risk of developing heart failure,” Pandey said during the presentation. “Further studies are needed to actually implement these strategies in real-world settings to see if we can truly prevent heart failure by implementation of effective therapies like SGLT2 inhibitors among high-risk individuals identified by this [screening method].”
Reference:
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Pandey A. Session 10 - Joint session with Circulation. Presented at: Heart in Diabetes CME Conference; June 7-9, 2024; Philadelphia.
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