NT-proBNP as an Effective Screening Tool for CVD in People with Diabetes

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Q1. Should we screen for heart failure in asymptomatic diabetes patients?

Asymptomatic cardiac dysfunction is common in diabetes and carries high mortality once symptomatic. Screening with NT-proBNP detects subclinical disease and allows early initiation of protective therapies (SGLT2i, ACE/ARB, MRA, GLP-1 RA). [3] 

Q2. Why is early heart failure frequently missed in people with diabetes?

Heart failure is one of the most common cardiovascular complications in both T1D and T2D, yet it often develops silently. Many patients remain asymptomatic until structural and functional myocardial damage has already occurred. Identifying Stage B (pre-clinical) heart failure offers a critical window to intervene early, before symptoms, hospitalisation, or irreversible damage occur. [1] 

Q3. What role does NT-proBNP play in early and actionable heart failure detection?

NT-proBNP is released in response to myocardial wall stress and reflects both systolic and diastolic dysfunction, often before symptoms arise. Clinical trials such as STOP-HF and PONTIAC demonstrated that biomarker-guided intensification of care reduces heart-failure hospitalisations. Based on this evidence, the ADA–ACC consensus and ADA 2025 Standards of Care recommend NT-proBNP screening in asymptomatic adults with diabetes who have additional cardiovascular risk factors.

Q4. What evidence supports the use of NT-proBNP for heart failure screening in asymptomatic patients?

The Optum real-world analysis (2016–2023) demonstrated that NT-proBNP predicts heart failure and mortality risk in both type 1 diabetes (T1D) and type 2 diabetes (T2D). [4] In 2022, the American Diabetes Association (ADA) and American College of Cardiology (ACC) issued a consensus framework ecommending biomarker-based screening for asymptomatic HF in diabetes. [1] The 2024–2025 ADA Standards of Care now formally endorse NT-proBNP testing for people with diabetes who have additional risk factors (e.g., hypertension, CKD, CAD, obesity). [3,6] 

Q5. What NT-proBNP levels should prompt action when screening for heart failure in people with diabetes?

The NT-proBNP cut-offs used in the University of Michigan screening program, aligned with ADA–ACC and ESC guidance, were ≥125 pg/mL in adults <75 years and ≥450 pg/mL in those ≥75 years. Abnormal results warrant optimisation of guideline-directed cardioprotective therapy (ACEi/ARB, SGLT2i, GLP-1 RA, MRA), avoidance of harmful drugs, and referral for echocardiography to assess cardiac structure and function. [5] 

Q6. How can biomarker-based screening be implemented effectively in routine clinical practice?

An  EHR-Based Trial at the University of Michigan automatically identified at-risk patients with diabetes who had not previously undergone NT-proBNP testing. One-click order sets simplified workflow, while abnormal results triggered embedded clinical guidance, including therapy optimisation and echocardiography referral. This approach enabled identification of under-treated patients and demonstrated that NT-proBNP-guided screening is feasible, scalable, and impactful in real-world care. [5]