Screening for CHF/Diastolic Dysfunction in DM Patients

This transcript has been edited for clarity.

Among those with diabetes, it has been long appreciated that they are at a higher risk of ischemic events.^[1] Heart attack and stroke is what I'm talking about, as well as amputation.^[1] What has less been appreciated is the high risk for heart failure that people with diabetes face over time.^[2] And this is true for heart failure with preserved ejection fraction, or heart failure with reduced ejection fraction; in the past, these were referred to as diastolic or systolic dysfunction.^[2,3] And both these forms of heart failure are much more common in people with diabetes than those without diabetes.^[1] 

At a minimum, everyone with diabetes should be screened with a history and physical for signs and symptoms of heart failure. Things such as lower extremity edema, for example. But beyond that, should we do more? Should everyone get an echocardiogram, for example? Should everyone get a BNP (brain natriuretic peptide) level drawn, in terms of blood work? These are great questions. 

Personally, I don't think there is a downside to checking a BNP.^[4] The cost is modest, it's a simple blood draw that can be obtained when other blood work is being obtained, and I think it can give insights into whether the patient is on a trajectory towards heart failure.^[4] It might not be immediately actionable in terms of starting new drugs, but it could raise awareness of that patient's particular heart failure risk.^[4]

As far as routine echocardiography, in the absence of any signs or symptoms, it's hard to actually endorse that. But I do think, in the future, as handheld technology, as handheld ultrasound becomes more common, as it becomes possible for patients to even get these sorts of tests on their own, I think it will happen, and I think we'll need to integrate that information.^[5] So for now, the answer is no. In a guideline dependent way, we cannot just start doing random testing because of concerns of cost and potential downstream testing that is induced. But I do think in the future, that might be part of our algorithms. 

For now, at least consider perhaps getting a BNP, and for sure, do a careful history and physical, thinking about potential heart failure, either with preserved or reduced ejection fraction.