Optimal Screening for Predicting and Preventing the Risk of Heart Failure Among Adults With Diabetes Without Atherosclerotic Cardiovascular Disease: a Pooled Cohort Analysis.

Background: The optimal approach to identify individuals with diabetes who are at 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≥12); N-terminal pro-B-type natriuretic peptide (NT-proBNP;≥125 pg/mL); high-sensitivity cardiac troponin (hs-cTnT ≥14 ng/L, hs-cTnI≥31 ng/L); echocardiography-based diabetic cardiomyopathy (echo-DbCM; LA enlargement, LV hypertrophy, or diastolic dysfunction). High-risk participants were also identified using 2-step screening strategies with a second test to additionally 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 (NNT 5 ) and number needed to screen (NNS 5 ) to prevent 1 HF event with an SGLT2i among high-risk participants, and cost of screening were estimated. Results: The initial study cohort included 6,293 participants (48.2% women), of which 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 NNT 5 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 low NNT 5 (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). 2-step screening strategies captured most HF events (75-89%) in the high-risk subgroup with a comparable NNT 5 as the 1-step screening approaches (30-32). The NNS 5 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 ($1,061) compared with other 2-step screening strategies (NT-proBNP/hs-cTn: $2,894; 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.