Standards of Care in Diabetes 2024: ADA releases new recommendations for screening of PAD and heart failure

The ADA's Standards of Care for 2024 include new recommendations to screen for heart failure, type 1 diabetes risk, and peripheral arterial disease (PAD), along with new obesity management guidance. It also includes new recommendations related to bone health and liver disease. The Standards of Care are essentially the global guidelines for the care of individuals with diabetes and those at risk.

The ADA's Professional Practice Committee developed the document via a scientific literature review. The panel comprised 21 professionals, including physicians from many specialities, certified diabetes care and education specialists, nurse practitioners, pharmacists, and dieticians.

This article will mainly focus on the ADA's updates on updated recommendations for screening peripheral arterial disease (PAD) and heart failure.

Atherosclerotic cardiovascular disease (ASCVD) defined as coronary heart disease (CHD), peripheral artery disease (PAD), or cerebrovascular disease is the leading cause of mortality and morbidity for people with diabetes. Addressing multiple cardiovascular risk factors (lipid control, glycemic, and blood pressure) can lead to large benefits.

Heart failure is another major cause of morbidity and mortality from cardiovascular disease.

The increased risk for heart failure in diabetic patients is classified as the presence of stage A heart failure, i.e., an increased risk for heart failure but without symptoms, structural heart disease, or biomarker evidence of myocardial strain. People with stage B heart failure are asymptomatic but have evidence of structural heart disease or functional cardiac abnormalities, including elevated biomarkers of myocardial strain or increased filling pressure. During these asymptomatic stages of heart failure, people with diabetes are at particularly high risk for progression to symptomatic stage C and D heart failure.

Recommendations For Heart Failure Screening

• The committee recommends considering screening asymptomatic adults with diabetes for the development of cardiac structural or functional abnormalities (stage B heart failure) by measurement of natriuretic peptides, including BNP or NT-proBNP levels.
• Risk stratification for incident heart failure (stage A) and identification of people with asymptomatic cardiac abnormalities (stage B) may prevent progression to the symptomatic stages of heart failure (stages C and D).
• People with diabetes and an elevated natriuretic peptide level without any symptoms of heart failure should be considered to have stage B heart failure, as there is evidence for increased filling pressure and wall strain.
• In people with diabetes and an abnormal natriuretic peptide level, echocardiography is recommended as the next step to screen for structural heart disease and echocardiographic Doppler indices for evidence of diastolic dysfunction and increased filling pressures.

Screening for Asymptomatic Peripheral Artery Disease in People With Diabetes

• The committee recommends screening for asymptomatic PAD using ankle-brachial index in people with diabetes at high risk for PAD, including any of the following: age ≥50 years, diabetes with duration ≥10 years, comorbid microvascular disease, clinical evidence of foot complications, or any end-organ damage from diabetes.
• The committee recommends screening people with diabetes and high risk for PAD, including those aged≥50 years, diabetes with duration ≥10 years, microvascular disease, clinical evidence of foot complications, or any end-organ damage from diabetes.

Screening for asymptomatic PAD may lead to early detection and treatment strategies to reduce the risk for progression of PAD and limb preservation. In addition, secondary prevention of PAD has been shown to reduce adverse cardiovascular and limb outcomes.

Reference:

American Diabetes Association Professional Practice Committee; 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2024. Diabetes Care 1 January 2024; 47 (Supplement_1): S179–S218. https://doi.org/10.2337/dc24-S010