Based on data from representatives, nearly 1 in 5 U.S. adults with type 2 diabetes but no symptoms of cardiovascular disease (CVD) have a marker of heart damage, the highly sensitive cardiac troponin T ( hs-cTnT) showing a clinically meaningful increase. A sample of over 10,000 US adults.
This finding suggests that hs-cTnT may be a useful marker for adult diabetes who may benefit from more aggressive CVD risk reduction despite the absence of clinical signs of CVD. are doing.
The results “highlight the enormous burden of asymptomatic CVD in people with diabetes and underscore the importance of early detection and treatment of CVD for this high-risk population,” the study authors said. published today in the Journal of the American Heart Association.
“This is the first study to investigate asymptomatic cardiovascular disease, defined by elevated cardiac biomarkers, in a nationally representative population of adults with and without diabetes. It provides new information about the high burden of cardiovascular disease.” [in American adults with diabetes] And the potential utility of hs-cTnT to monitor this risk in people with diabetes,” said Elizabeth Selvin, Ph.D., lead author and professor of epidemiology at the Bloomberg School of Public Health at Johns Hopkins University in Baltimore. .
“What we are seeing is that many people with type 2 diabetes who have no history of heart attack or cardiovascular disease are at increased risk for cardiovascular complications,” Selvin added in the AHA press release. rice field. According to the CDC, about 27 million adults in the United States have been diagnosed with type 2 diabetes, some at low risk of cardiovascular disease and others at high risk. So the open question is “who is most at risk?” These cardiac biomarkers provide insight into cardiovascular risk in people who are otherwise not perceived to be at highest risk. ”
“Our results provide evidence to support the use of cardiac biomarkers in routine risk monitoring in high-risk populations such as those with diabetes,” Selvin said in an interview.
Need for proactive CVD risk reduction
The results of the study also suggest that people with diabetes and elevated hs-cTnT should take “aggressive interventions, including lifestyle interventions, weight loss, treatment with statins, antihypertensive drugs, and cardioprotective therapies such as sodium and glucose cotransporters.” It should also be a target for cardiovascular risk reduction.” 2 (SGLT-2) inhibitor and a glucagon-like peptide-1 (GLP-1) receptor agonist,” Selvin added.
“Cholesterol is often the factor we target to reduce the risk of cardiovascular disease in people with type 2 diabetes,” she observes. “However, type 2 diabetes can directly affect the heart, independent of cholesterol levels. If so, cholesterol-lowering drugs won’t work because they prevent heart damage,” Selvin explains. “Our study suggests that additional nonstatin-related treatments are needed to reduce the risk of cardiovascular disease in people with type 2 diabetes.”
However, a necessary step before formally recommending such a strategy is the effectiveness of certain treatments, such as SGLT-2 inhibitors and GLP-1 agonists, in people with diabetes and elevated hs-cTnT. to conduct clinical trials that assess sexuality, she points out.
“Randomized controlled trials are the best way to test the relevance of measuring these biomarkers to assess risk in asymptomatic patients with diabetes,” says HS- A prospective study of the value of cTnT commented Robert H. Eckel, M.D., Ph.D. An endocrinologist at the University of Colorado Anschutz Medical Center in Aurora.
“I doubt the measurements [of hs-cTnT] will be refunded [by third-party payers] If conducted without such outcome data,” he added.
Eckel also further validated the association between elevated hs-cTnT and CVD events in adult diabetes in an additional cohort, showing elevated levels of another cardiac biomarker, N-terminal pro-B-type natriuretic peptide (NT). emphasizes the need to check -proBNP) — less functional than troponin as a risk marker for diabetics, again found in research.
ADA report already recommends testing for these biomarkers for HF
however, Consensus report to be published in 2022 The American Diabetes Association has published a case study of routine and regular measurement of both sensitive cardiac troponin and natriuretic peptide levels in diabetic patients for early detection of heart failure.
“Among patients with diabetes, at least annual natriuretic peptide or high-sensitivity cardiac troponin measurements are recommended to identify early stages of heart failure and implement strategies to prevent progression to symptomatic heart failure. ,” states the ADA Consensus Report. heart failure.
In a new study by Selbin and co-authors, National Health and Nutrition Survey (NHANES) included US adults at least 20 years of age with no history of CVD such as myocardial infarction, stroke, coronary heart disease, or heart failure between 1999 and 2004. This included 9,273 without diabetes and 1,031 with previous diagnosis or diabetes defined as A1c ≥ 6.5%.
“Cardiovascular risk varies widely among adults with type 2 diabetes, highlighting the need for accurate risk stratification,” the authors say.
All study participants recorded measurements of hs-cTnT and NT-proBNP.
Investigators considered hs-cTnT levels above 14 ng/L and NT-proBNP levels above 125 pg/mL as indicators of asymptomatic CVD.
The rough prevalence of elevated NT-proBNP was 33.4% in diabetic patients and 16.1% in non-diabetic patients. Elevated hs-cTnT occurred in 19% of diabetic patients and 5% of non-diabetic patients. Elevated levels of both markers were present in 9% of diabetics and 3% of non-diabetics.
“Approximately 1 in 3 adults with diabetes have asymptomatic CVD, 19% have elevated hs-cTnT levels, 23% have elevated NT-proBNP, and 9% have elevated both cardiac biomarkers. ,” the researchers noted.
Diabetes is associated with elevated hs-cTnT and a doubling of prevalence
After adjusting for several demographic variables and traditional CVD risk factors, diabetics had a significantly higher hs-cTnT elevation of 98% compared with non-diabetics. However, after similar adjustments, the diabetic patient’s rate of NT-proBNP elevation was significantly lower than in controls, a relative decrease of 24%.
“Our findings suggest that hs-cTnT may be more useful in patients with diabetes.” [than NT-proBNP] It’s less complicated to interpret, so it’s better suited for general risk monitoring,” Selvin said, explaining that “NT-proBNP is affected by overweight and obesity.”
Among diabetics, the age-adjusted prevalence of elevated hs-cTnT was higher in those with longer duration of diabetes and in those with higher A1c levels but poorly controlled diabetes. None of these factors showed a significant relationship with measured levels of NT-proBNP.
Further analysis linked the NHANES findings from 1999 to 2004 with US national death records through the end of 2019. This indicated that increased levels of both hs-cTnT and NT-proBNP were significantly associated with increased subsequent all-cause mortality in diabetic patients. After adjusting for demographic variables and CVD risk factors, elevated hs-cTnT was associated with a 77% increase in mortality compared with diabetic patients, and elevated NT-proBNP with a 78% increase compared with diabetic patients. and these markers were not elevated.
However, for cardiovascular death outcome, elevated hs-cTnT was associated with a non-significant 54% relative increase, while elevated NT-proBNP was associated with a 2.46-fold significant relative increase.
The study “adds new data on biomarkers not routinely measured in asymptomatic people with or without diabetes” and explores the relationship between these markers and CVD and all-cause mortality. Eckel concluded.
No commercial funding was provided for this study, but reagents donated by Abbott Laboratories, Ortho Clinical Diagnostics, Roche Diagnostics, and Siemens Healthcare Diagnostics were used. Used. Servin and Eckel did not disclose anything.
J. Am Hart Society Published online May 31, 2023. full text
Mitchel L. Zoler is a Medscape and MDedge reporter based in the Philadelphia area. @mitchelzoler
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