Key result
Two-step WATCH-DM and NT-proBNP screening identifies high-risk diabetes patients with an NNT of ~43 for SGLT2i.
Why the study?
The optimal approach to identify individuals with diabetes at high risk for developing heart failure to inform preventive therapies is unknown, especially in those without ASCVD.
Does a 2-step risk screening strategy accurately and cost-effectively identify adults with diabetes and no ASCVD who are at high risk for incident heart failure to target for prevention with SGLT2 inhibitors?
Cohort (n=6,293)
Yes
Does a 2-step risk screening strategy accurately and cost-effectively identify adults with diabetes and no ASCVD who are at high risk for incident heart failure to target for prevention with SGLT2 inhibitors?
Number Needed to Treat: 43 (95% CI 29–72)
Number Needed to Treat: 43
A 2-step screening approach utilizing a clinical risk score (WATCH-DM) followed by selective biomarker testing (NT-proBNP) efficiently and cost-effectively identifies patients with diabetes who derive significant absolute benefit from SGLT2 inhibitors for primary heart failure prevention.
May support targeted SGLT2i use via 2-step screening in diabetes without ASCVD; leaves open prospective validation of HF prevention.
BACKGROUND: The optimal approach to identify individuals with diabetes who are at a high risk for developing heart failure (HF) to inform implementation of preventive therapies is unknown, especially in those without atherosclerotic cardiovascular disease (ASCVD). METHODS: Adults with diabetes and no HF at baseline from 7 community-based cohorts were included. Participants without ASCVD who were at high risk for developing HF were identified using 1-step screening strategies: risk score (WATCH-DM [Weight, Age, Hypertension, Creatinine, HDL-C, Diabetes Control, QRS Duration, MI, and CABG] ≥12), NT-proBNP (N-terminal pro-B-type natriuretic peptide ≥125 pg/mL), hs-cTn (high-sensitivity cardiac troponin T ≥14 ng/L; hs-cTnI ≥31 ng/L), and echocardiography-based diabetic cardiomyopathy (echo-DbCM; left atrial enlargement, left ventricular hypertrophy, or diastolic dysfunction). High-risk participants were also identified using 2-step screening strategies with a second test to identify residual risk among those deemed low risk by the first test: WATCH-DM/NT-proBNP, NT-proBNP/hs-cTn, NT-proBNP/echo-DbCM. Across screening strategies, the proportion of HF events identified, 5-year number needed to treat and number needed to screen to prevent 1 HF event with an SGLT2i (sodium-glucose cotransporter 2 inhibitor) among high-risk participants, and cost of screening were estimated. RESULTS: The initial study cohort included 6293 participants (48.2% women), of whom 77.7% without prevalent ASCVD were evaluated with different HF screening strategies. At 5-year follow-up, 6.2% of participants without ASCVD developed incident HF. The 5-year number needed to treat to prevent 1 HF event with an SGLT2i among participants without ASCVD was 43 (95% CI, 29-72). In the cohort without ASCVD, high-risk participants identified using 1-step screening strategies had a low 5-year number needed to treat (22 for NT-proBNP to 37 for echo-DbCM). However, a substantial proportion of HF events occurred among participants identified as low risk using 1-step screening approaches (29% for echo-DbCM to 47% for hs-cTn). Two-step screening strategies captured most HF events (75-89%) in the high-risk subgroup with a comparable 5-year number needed to treat as the 1-step screening approaches (30-32). The 5-year number needed to screen to prevent 1 HF event was similar across 2-step screening strategies (45-61). However, the number of tests and associated costs were lowest for WATCH-DM/NT-proBNP ($1061) compared with other 2-step screening strategies (NT-proBNP/hs-cTn: $2894; NT-proBNP/echo-DbCM: $16 358). CONCLUSIONS: Selective NT-proBNP testing based on the WATCH-DM score efficiently identified a high-risk primary prevention population with diabetes expected to derive marked absolute benefits from SGLT2i to prevent HF.
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Patel et al. (2023) conducted a cohort in Diabetes without prevalent heart failure (n=6,293). Heart failure risk screening strategies (1-step vs 2-step) vs. Low-risk participants or alternative screening strategies was evaluated on Incident heart failure (hospitalization for HF, outpatient HF, or HF-associated death) at 5 years among participants without ASCVD (NNT 43, 95% CI 29-72). A 2-step screening strategy using the WATCH-DM risk score followed by selective NT-proBNP testing efficiently identified high-risk patients with diabetes who are expected to derive marked absolute benefits from SGLT2 inhibitors for HF prevention.
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