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Heart failure and diabetes mellitus


Assessment and screening

Cost-effectiveness of screening strategies to detect heart failure in patients with type 2 diabetes

This paper evaluates five screening strategies for heart failure in elderly patients with type 2 diabetes using a Markov decision analytic cohort model of heart failure progression and a cohort of 581 Dutch patients.

Summary points
  • A significant proportion of elderly patients with type 2 diabetes have unrecognized heart failure. Routine screening of elderly patients with diabetes for heart failure will require additional healthcare expenditure. However, it is expected to improve outcomes and may reduce costs in the long-term.
  • The aim of this study was to assess the long-term health effect and costs of five screening strategies to detect heart failure in elderly patients with type 2 diabetes in the Dutch primary care setting.
  • Five screening strategies were assessed:
    • EMR/symptoms; a strategy based on information available from the Electronic Medical Record (EMR) of general practitioners combined with the assessment of presence of dyspnea, fatigue, ankle edema, nocturia and palpitations.
    • EMR/symptoms/physical exam; strategy 1 plus physical examination (PE).
    • EMR/symptoms/physical exam/NTproBNP; strategy 2 plus measurement of natriuretic peptide (NTproBNP).
    • EMR/symptoms/physical exam/NTproBNP/ECG; strategy 3 plus ECG.
    • Echocardiography.
  • Health effects were measured as expected life-years and quality-adjusted life-years (QALYs). A specially developed Markov decision analytic cohort model of heart failure progression was used to assess the costs.
  • The patient population consisted of 581 patients with type 2 diabetes and aged ≥60 years.
  • Patients were required not have a diagnosis of heart failure.
  • For willingness to pay values ranging from €6050/QALY to €31,000/QALY for men and from €6300/QALY to €42,000/QALY for women, the EMR/symptoms strategy had the highest probability of being cost-effective. For lower willingness to pay values, usual care (no screening) strategy was optimal, while for higher willingness to pay values, direct echocardiography was preferable.
  • Cost-effectiveness of all screening strategies improved with the increase in effectiveness of treatment for heart failure.
  • The simplicity of the EMR/symptoms strategy makes it possible to implement within the framework of existing diabetes management programs in primary care.

van Giessen A et al. Cardiovasc Diabetol 2016; 15: 48. doi: 10.1186/s12933-016-0363-z

Assessing cardiovascular risk and testing in type 2 diabetes

This review discusses the state of the art of risk factors, biomarkers, and subclinical disease parameters potentially useful in cardiovascular risk assessment in type 2 diabetes.

Summary points
  • The recommendations for the management of patients with type 2 diabetes provided in the American Heart Association (AHA)/American Diabetes Association (ADA) and the European Society of Cardiology (ESC) guidelines vary based an individual’s risk profile.
  • Risk factors traditionally used in the assessment of patients with diabetes include blood pressure, low-density lipoprotein (LDL) cholesterol, triglycerides and hemoglobin A1c. The evidence of the prognostic value of other risk factors, such as LDL particle concentration, non-high-density lipoprotein (HDL) cholesterol, apolipoprotein B and HDL cholesterol, is less convincing.
  • A number of biomarkers, including highly-sensitive C-reactive protein (hs-CRP), N-terminal pro–B-type natriuretic peptide (NTproBNP), cardiac troponins T and I and urine albumin, have been shown, to varying degrees, to predict cardiovascular risk and can be used in the assessment of patients with diabetes.
  • Electrocardiography, coronary calcium score, non-ionizing radiation ultrasound measurement of the thickness of carotid intima-media and myocardial perfusion scintigraphy have been shown to be useful in the clinical evaluation of cardiovascular risk in patients with diabetes.
  • In addition, screening for diabetic retinopathy and neuropathy can be used to assess cardiovascular risk.
  • An individualized approach to cardiovascular risk management in patients with type 2 diabetes should be used.

Saeed A, Ballantyne CM. Curr Cardiol Rep 2017; 19: 19. doi: 10.1007/s11886-017-0831-4

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