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Two-step screening better identifies diabetics at risk of heart failure

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Two-step screening better identifies diabetics at risk of heart failure

Researchers have identified an efficient and cost-effective two-step screening strategy that, compared to the current one-step approach, more accurately identifies which type 2 diabetics need treatment to prevent life-threatening heart failure, even those considered low-risk following only a clinical assessment.

Diabetes is a well-established risk factor for cardiovascular disease (CVD). Compared to people without diabetes, type 2 diabetics have a considerably higher risk of cardiovascular morbidity and mortality and have over twice the risk of developing heart failure, a serious condition that worsens over time and is eventually fatal.

A new study led by researchers at the University of Texas Southwestern (UTSW) Medical Center examined what screening protocols were most effective at identifying type 2 diabetics who needed medication to prevent heart failure, even if they’re considered low-risk.

“Diabetes often leads to cardiovascular disease, with heart failure being one of the most common manifestations,” said Ambarish Pandey, corresponding author of the study. “In recent years, many physicians have relied on one-step screening approaches, like clinical risk scores, biomarker tests, or echocardiography, to identify those at high-risk for developing heart failure. But even patients considered low-risk by these single-step risk assessment tools sometimes develop heart failure. Furthermore, testing all individuals with diabetes with often expensive biomarker or echo assessments is often not feasible or cost-effective.”

The researchers looked at data from 6,293 diabetic patients who’d taken part in seven cohort studies. Of those, 4,889 had no signs of atherosclerotic cardiovascular disease (ASCVD), the buildup of fats, cholesterol, and other substances that can block arteries, starving the heart of blood and oxygen. All patients had undergone screening to determine their level of risk for heart failure. By comparing screening methods and downstream risk of heart failure episodes at a five-year follow-up, the researchers determined the screening protocols that best predicted those at risk.

“Our study found that 30% to 50% of the total heart failure events in the population without prevalent ASCVD occurred in individuals marked as low-risk with a single screening strategy,” Pandey said. “But when a second step was added, approximately 85% of the actual heart failure cases were identified. This suggests a substantial percentage of patients with diabetes who could benefit from more aggressive preventive treatment are being overlooked.”

Different two-step screening protocols were evaluated, incorporating the WATCH-DM score (a quick assessment tool that predicts a diabetic’s risk of heart failure), blood biomarkers, including natriuretic peptide levels (proteins produced when there’s stressful stretching of the heart muscle), and echocardiography (uses sound waves to check the heart’s structure and function).

“We found that assessing the WATCH-DM risk score in all individuals, followed by natriuretic peptides only among individuals who were considered low-risk based on the WATCH-DM risk score, was the most efficient of the two-step screening strategies to assess heart failure risk and target preventive therapies,” said Kershaw Patel, the study’s lead author.

Preventive therapies include sodium-glucose cotransporter-2 (SGLT2) inhibitors. Originally known as drugs to control high blood glucose levels, SGLT2 inhibitors have established themselves as a pivotal heart failure therapy to protect heart health. A 2021 meta-analysis of 15 trials and over 20,000 patients found that SGLT2 inhibitors significantly reduced all-cause mortality, cardiovascular mortality, and heart failure hospitalizations.

Echocardiographic screening didn’t feature prominently in the two-step approach proposed by the researchers. Although it’s beneficial to risk determination following clinical assessment, an echo is more expensive and time-consuming than a natriuretic peptide blood test, meaning it’s less likely to be checked unless a patient is already considered high-risk or there’s another indication for performing the procedure.

“The key to improving our ability to identify those most in need of preventive treatment is using cost-effective screening tools that can be easily implemented in the clinic,” said Pandey. “Our finding advances the field by demonstrating an efficient and effective approach that gives physicians a better idea of their patients’ actual risk. Our hope is that further study of this two-step strategy will enable us to evaluate both its clinical success and its cost-effectiveness to develop a consistent approach for patients.”

The study was published in the journal Circulation.

Source: UTSW Medical Center

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