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Daily Dose: Subclinical CVD Affects 1 in 3 US Adults with Diabetes


Patient Care brings primary care clinicians a lot of medical news every day—it’s easy to miss an important study. The Daily Dose provides a concise summary of one of the website's leading stories you may not have seen.

On May 31, 2023, we reported on a study published in the Journal of the American Heart Association that characterized the burden and prognostic value of subclinical cardiovascular disease (CVD), as assessed by elevated high-sensitivity cardiac troponin (hs-cTn) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), in adults in the US with and without diabetes.

The study

The study cohort was drawn from the 1999 - 2004 National Health and Nutrition Examination Survey (NHANES) and included nonpregnant adults aged ≥20 years without self-reported CVD, and with valid measures of NT-proBNP, hs-cTnT, and covariates. The final number of participants for analysis was 10 304.

Participants were categorized as having no diabetes, newly diagnosed diabetes (≤1 year or no self-reported diagnosed diabetes and HbA1c ≥6.5%), short diabetes duration (self-reported diagnosis between 1 and 10 years), and long diabetes duration (≥10 years).

Using stored blood samples, researchers defined subclinical CVD as having either elevated hs-cTnT (≥14 ng/L) or NT-proBNP (≥125 pg/mL) levels. Mortality status was determined via rough linkage to the National Death Index from baseline until December 31, 2019. CV mortality specifically was defined as heart disease or cerebrovascular disease listed as underlying cause of death. After adjusting for age, race, income and cardiovascular risk factors, they assessed the associations among elevated NT-proBNP and hs-cTnT with risk of death from cardiovascular death or all causes.

The findings

From 1999 - 2004, 7% of US adults without a history of CVD had diabetes and were generally older and had a higher burden of CV risk factors. Distributions of both hs-cTnTand NT-proBNP were right skewed, according to the study results, and median levels of both were higher among those with vs those without T2D.

The prevalence of any subclinical CVD, the authors found, was twice as high for adults with T2D (33.4%) vs those without (16.1%). They report that differences in biomarker levels by T2D status were particularly pronounced for hs-cTnT(19% with T2D vs 5% without T2D). Although the prevalence of having elevations in both biomarkers was low, it was significantly higher in adults with (9%) vs without (3%) T2D.

In models adjusted for age, elevated hs-CTnT, but not elevated NT-proBNP, was found more common in adults with T2D, overall and across age, sex, race and ethnicity, and weight status. In contrast, after adjusting for age, NT-proBNP levels were not elevated in those with T2D compared to those without.

Further analysis found that prevalence of elevated hs-cTnT among those with T2D was significantly higher in individuals with longer disease duration and suboptimal glycemic control.

When the investigators analyzed the association between the 2 biomarkers and mortality among adults with T2D, elevated levels of hs-cTnT were independently associated with an adjusted 77% increased risk of all-cause mortality (95% CI, 1.33 - 2.34) and elevated levels of NT-proBNP with a 78% increased risk (95% CI, 1.26 - 2.51). There was also an independent association between elevated levels of both proteins and increased risk of CVD mortality, ie, 54% for hs-cTnT (95% CI, 0.83 - 2.85) and more than twice that level of heightened risk for NT-proBNP (aHR, 2.46; 95% CI, 1.31 - 4.60).

Clinical implications

"The substantial burden of subclinical cardiovascular disease in adults with diabetes highlights the urgent need for prevention. Cardiac biomarkers may be useful for assessing and monitoring risk in persons with diabetes in the general population."

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