Dr Bee Yong Mong
Head and Senior Consultant, Department of Endocrinology, Singapore General Hospital;Vice-President, Diabetes Singapore

Management of CVD in Patients with Diabetes


  • The latest ADA/ACC consensus & ESC guidelines recommends incorporating biomarkers measurements, such as natriuretic peptide and high-sensitivity cardiac troponin, on an annual basis, to assess cardiovascular risk amongst individuals with diabetes.
  • Clinical implementation of the ESC guidelines for HF screening among diabetes patients in APAC requires raising awareness, education, and easier access to biomarkers.
  • Early CVD risk stratification among diabetes patients can be possible with primary care physicians adopting the NT-proBNP measurement as part of their annual routine blood work.

How would the recent 2022 ADA consensus and 2023 ESC recommendations help physicians mitigate CVD risk in T2DM patients?

It is widely recognised that individuals with type 2 diabetes are at increased risk of developing cardiovascular diseases such as coronary heart disease, peripheral artery disease and stroke.

What is less well-recognised by physicians is that heart failure is also a common complication of diabetes, with a prevalence of up to 22% in individuals with diabetes. Heart failure is under-appreciated and, as a result, sub-optimally screened, diagnosed and prevented from worsening. Studies have found that the rates of incident heart failure hospitalisation were twofold higher in people with diabetes compared to those without.

The recent ADA and ESC consensus recommendations thus provide the necessary guidance on the management of cardiovascular disease in patients with diabetes. The recommendations include cardiovascular risk assessment and reduction, and, for the first time, heart failure testing recommendations for individuals with diabetes have been included in these recommendations, putting additional emphasis on this complication.

One such recommendation is incorporating biomarkers measurements, such as natriuretic peptide and high-sensitivity cardiac troponin, to identify at-risk individuals for early institution of preventive measures before heart failure is even symptomatic.

I believe widespread adoption of these guidelines can go a long way to mitigate cardiovascular risk and improve outcomes in type 2 diabetes patients.

How can the 2023 ESC guideline recommendations on using biomarkers for screening T2DM patients suspected of HF be translated into clinical practice in the APAC region?

Translating the 2023 European Society of Cardiology guideline recommendation on using biomarkers for screening type 2 diabetes patients suspected of heart failure can be challenging, but we can adopt a 3-prong approach.

First, physicians should be reminded that heart failure represents a major cardiovascular complication in this vulnerable population. In other words, we need to raise the awareness of this complication. Heart failure may be the first presentation of cardiovascular disease in many individuals with diabetes. Hence, screening and early detection of at-risk individuals are essential.

Second, this recommendation on using biomarkers for screening type 2 diabetes patients must be made known to endocrinologists, diabetologists and primary care physicians, as they look after most individuals with asymptomatic diabetes. This is important because the guideline provides clear, evidence-based guidance to physicians on the best approaches for screening and diagnosing heart failure, including the asymptomatic phase. Third, health systems should make biomarkers such as NT-proBNP easily accessible to clinicians to facilitate this proactive screening of individuals with diabetes. These biomarkers can help identify patients with heart failure earlier in the disease course so lifestyle interventions or medications can be started sooner.

From your clinical experience, what is the T2DM patient profile most suited for screening with NT-proBNP? How often should screening be conducted?

Based on my experience, all patients with type 2 diabetes should undergo screening with NT-proBNP at the first visit or consultation. We should not second guess who should receive the screening but instead add this test to the routine blood work for all patients.

If the levels are elevated, further evaluation with chest X-rays and echocardiography are appropriate. If the levels are normal, I recommend repeating the measurement on an annual basis in accordance with the ADA guidelines. This is important because cardiovascular risk is not static, and serial monitoring of NT-proBNP is beneficial.

What is the current practice of assessing T2DM patients for CVD risk by Endocrinologists?

Before the release of the ADA guidance, endocrinologists rely on conventional risk factors such as age, family history, body mass index, blood pressure, glycated haemoglobin, lipids and albuminuria for cardiovascular risk assessment. The limitation or drawback is that these risk factors are not cardiac-specific and do not have a high predictive ability of heart failure.

Other than risk factors, cardiovascular risk scores have been developed to assess cardiovascular risk for type 2 diabetes patients. However, while these risk scores can help with cardiovascular risk stratification, their adoption in clinical practice is generally poor in many regions, and their clinical benefit has yet to be proven. Therefore, endocrinologists require a better tool for assessing the cardiovascular risk for our diabetes patients.

How can primary care physicians play a vital role in screening their T2DM patients for early CVD risk stratification?

The primary care physicians manage most individuals with type 2 diabetes in many countries. Hence, they are the first line of defence, and they can play an important role in early cardiovascular risk stratification by incorporating the measurement of biomarkers, such as NT-proBNP, in the care pathway.

In other words, primary care physicians should add NT-proBNP measurement to the routine blood work for these patients annually. To avoid missing out on the test, I strongly encourage physicians to bundle the biomarker measurement as part of the annual screening for diabetic complications which all diabetes patients undergo.

Appropriate follow-up actions should then be instituted if the levels are elevated.

How would you encourage your peers in the APAC region to improve HF risk stratification in their T2DM patients, as per the 2023 ESC guidelines?

It is essential first to raise awareness of the strong link between diabetes and heart failure among physicians in the APAC region. Asian patients have been found to develop heart failure about ten years earlier than their Western counterparts. Therefore, early detection, prevention and treatment are important.

The broader community in APAC region also needs to recognise that simple tests, in the form of NT-proBNP measurement, can significantly improve cardiovascular and heart failure risk stratification in type 2 diabetes patients. Physicians should also enhance their familiarity with this biomarker and ensure the test is available in their health systems.

Lastly, the recommendations from ADA and ESC should be incorporated into the local guidelines of the respective countries in the APAC region to accelerate the translation of guidelines into clinical practice.

I hope these strategies can help to facilitate early detection of cardiovascular disease and heart failure in type 2 diabetes patients, allowing prompt interventions to prevent heart failure progression in this region.

Updates from Leading Experts

STRONG-HF: Post-discharge Heart Failure Management and Implementation of GDMT Heart Failure Therapy

Prof Alexandre Mebazaa shares the key results and highlights from the STRONG-HF study that assessed the safety, tolerability of optimization of guideline directed medical therapy. [...]


CANVAS study: NT-proBNP and CVD risk reduction

Can you give us a short description of the CANVAS program? The CANVAS program was a set of two trials, whose goal was to evaluate the role of an SGLT2...

1 July 2021
Dr James L Januzzi