What is the role of B-type natriuretic peptide (BNP) screening in diabetic patients?

From the Guidelines

BNP screening is a valuable tool in diabetic patients for the early detection of heart failure, and it should be considered in high-risk patients, particularly those with additional risk factors like hypertension, coronary artery disease, or diabetic cardiomyopathy, as it can guide earlier intervention and potentially slow heart failure progression 1.

Role of BNP Screening in Diabetic Patients

BNP testing measures BNP or NT-proBNP levels in blood, with values above 100 pg/mL for BNP or 300 pg/mL for NT-proBNP suggesting possible heart failure in diabetics.

• BNP works as a biomarker because it's released by ventricular cardiomyocytes in response to increased wall tension and volume overload, making it an effective indicator of cardiac stress before clinical symptoms become apparent.
• The increased risk for heart failure in people with diabetes is classified as the presence of stage A heart failure, i.e., an increased risk for heart failure but without symptoms, structural heart disease, or biomarker evidence of myocardial strain 1.
• Results from several randomized controlled trials revealed that more intensive treatment of risk factors in people with increased levels of natriuretic peptides reduces the risk for symptomatic heart failure, heart failure hospitalization, and newly diagnosed left ventricular dysfunction 1.

Benefits of BNP Screening

• BNP screening can guide earlier intervention with medications like ACE inhibitors, ARBs, SGLT2 inhibitors, or beta-blockers, potentially slowing heart failure progression in diabetic patients.
• Regular screening may be beneficial in high-risk diabetic patients, particularly those with additional risk factors like hypertension, coronary artery disease, or diabetic cardiomyopathy.
• Identification, risk stratification, and early treatment of risk factors in people with diabetes and asymptomatic stages of heart failure reduce the risk for progression to symptomatic heart failure 1.

Clinical Considerations

• BNP levels should be interpreted cautiously in women and in people over 60 years of age who do not have HF, as levels may be elevated meaningfully in these individuals without HF 1.
• Elevated BNP levels may lend weight to a suspected diagnosis of HF or trigger consideration of HF when the diagnosis is unknown but should not be used in isolation to confirm or exclude the presence of HF 1.

From the Research

BNP Screening in Diabetic Patients

• B-type natriuretic peptide (BNP) screening plays a significant role in identifying diabetic patients at high risk for developing heart failure (HF) 2.
• The optimal approach to identify individuals with diabetes who are at a high risk for developing HF is unknown, especially in those without atherosclerotic cardiovascular disease (ASCVD) 2.
• Studies have shown that BNP levels are affected by glycemic control, and poor glycemic control may cause high levels of BNP, leading to overdiagnosis of congestive heart failure 3.

Role of BNP in Cardiovascular Risk Assessment

• BNP has been established as a biomarker for various cardiovascular diseases, including heart failure, atrial fibrillation, and pulmonary hypertension 4.
• BNP assay has widespread utility as an adjunct to cardiovascular disease diagnosis and management 4.
• In diabetic patients, BNP screening can help identify those at high risk for cardiovascular events, allowing for early intervention and prevention strategies 5.

Screening Strategies for BNP

• One-step screening strategies, such as NT-proBNP, hs-cTn, and echocardiography-based diabetic cardiomyopathy, can identify high-risk participants, but may miss a substantial proportion of HF events 2.
• Two-step screening strategies, such as WATCH-DM/NT-proBNP, NT-proBNP/hs-cTn, and NT-proBNP/echo-DbCM, can capture most HF events and provide a comparable 5-year number needed to treat as the 1-step screening approaches 2.
• Selective NT-proBNP testing based on the WATCH-DM score can efficiently identify a high-risk primary prevention population with diabetes expected to derive marked absolute benefits from SGLT2i to prevent HF 2.

Clinical Implications

• BNP screening can help clinicians identify diabetic patients at high risk for cardiovascular events and guide treatment decisions, such as the use of SGLT2i to prevent HF 2, 5.
• Glycemic control should be considered when interpreting BNP levels, as poor glycemic control may affect BNP levels and lead to overdiagnosis of congestive heart failure 3.
• Further research is needed to fully understand the role of BNP screening in diabetic patients and to develop effective screening strategies for cardiovascular risk assessment 6, 5.