Heart failure in diabetes: when to look for it, how to find it

Abstract

Heart failure (HF) is a chronically underestimated complication of diabetes mellitus (DM). The American Diabetes Association consensus describes an HF prevalence of up to 22% in people with DM, with incidence continuing to rise¹. HF can develop in patients with DM even in the absence of hypertension, coronary artery disease, or valvular disease, and it frequently represents their first cardiovascular manifestation¹, making it a priority outcome to monitor in DM2.

When should it be assessed? From risk to Stage B

The current paradigm proposes moving HF assessment forward from Stage C (symptomatic disease) to Stage B (asymptomatic structural heart disease). The 2023 ESC Guidelines include HF among the manifestations to be considered when stratifying cardiovascular risk in patients with diabetes⁴. The ADA Standards of Care in Diabetes—2025 recommend considering screening asymptomatic adults using natriuretic peptides to prevent progression to Stage C HF2. However, a critical analysis published in Diabetes Care points out that NT-proBNP has limited performance as a population-level screening test and that questions remain regarding the natural history of Stage B disease, the appropriate management of a positive result, and the cost-effectiveness of systematic screening³. The recommendation is well supported, but its implementation requires clinical judgment.

How can it be detected? Biomarkers and the diagnostic algorithm

BNP or its inactive fragment, NT-proBNP, provides the entry point to the diagnostic algorithm. The Heart Failure Association of the ESC has established algorithms to guide decisions regarding when an elevated value should prompt referral for echocardiography⁷. Two landmark trials support this strategy: PONTIAC showed that, in people with type 2 diabetes and elevated NT-proBNP without known heart disease, biomarker-guided intensification of neurohormonal therapy reduced major cardiovascular events⁵. STOP-HF showed that screening with natriuretic peptides combined with collaborative cardiology follow-up reduced newly diagnosed left ventricular dysfunction, emergency HF, and combined major cardiovascular events6.

HF should be incorporated as an explicit surveillance target in every patient with type 2 diabetes, beyond glycemic control and conventional coronary prevention. Measurement of a natriuretic peptide, with referral for echocardiography when the level is elevated, makes it possible to move diagnosis forward to Stage B, when therapeutic intervention is more likely to modify the course of the disease¹. Detecting HF early can make the difference between diagnosing incipient disease and diagnosing it only after the patient presents to the emergency department.