Research Highlights:
- One-third of adults in the U.S. with Type 2 diabetes may have symptomless or undetected cardiovascular disease.
- Adults with Type 2 diabetes who do not have any signs or symptoms of cardiovascular disease are more likely to have elevated levels of two proteins linked to heart disease than peers without Type 2 diabetes. These cardiac biomarkers are associated with an increased risk of death from cardiovascular disease and any cause.
- The findings suggest that routine screening for these two cardiac biomarkers and more tailored interventions may help to reduce the risk of cardiovascular disease events in this high-risk population.
Newswise — 1 out of every 3 adults diagnosed with Type 2 diabetes might harbor undetected cardiovascular disease. Recent research published in the Journal of the American Heart Association, an open access and peer-reviewed journal by the American Heart Association, reveals that elevated levels of two protein biomarkers, indicating heart damage, were found to be linked with undetected or symptomless cardiovascular disease in adults with Type 2 diabetes when compared to individuals without Type 2 diabetes.
High-sensitivity cardiac troponin T and N-terminal pro-B-type natriuretic peptide biomarkers are employed to assess heart injury and stress. Typically utilized for diagnosing heart attack and heart failure, these tests can also detect slight elevations in the levels of these proteins in the blood. Such mild increases may serve as an early indication of alterations in the heart's structure and function, potentially raising the risk of future heart failure, coronary heart disease, or mortality.
"We are observing a significant risk of cardiovascular complications in many individuals with Type 2 diabetes, even among those who have not experienced a heart attack or prior cardiovascular issues," stated Elizabeth Selvin, Ph.D., M.P.H., a professor of epidemiology at Johns Hopkins Bloomberg School of Public Health in Baltimore and co-author of the study. With approximately 27 million adults in the U.S. diagnosed with Type 2 diabetes, as reported by the CDC, the population encompasses both low and high cardiovascular disease risk individuals. The crucial question then becomes, "Who is most susceptible to such risks?" The utilization of these cardiac biomarkers allows us to gain insights into the cardiovascular risk in individuals who may not be readily identified as being at the highest risk.
The study involved an analysis of health data and blood samples from over 10,300 adults who participated in the U.S. National Health and Nutrition Examination Survey between 1999 and 2004. The primary objective was to investigate whether elevated levels of cardiac protein biomarkers could serve as indicators of previously undetected cardiovascular disease in individuals with and without Type 2 diabetes, even in the absence of symptoms. All participants enrolled in the study had reported no prior history of cardiovascular disease.
To examine the associations between elevated levels of troponin and N-terminal pro-B-type natriuretic peptide, researchers utilized stored blood samples obtained from all participants in the study. Additionally, they collected mortality data from the National Death Index. By considering factors such as age, race, income, and cardiovascular risk factors, the researchers adjusted the analysis. They then evaluated the relationships between elevated levels of these cardiac biomarkers and the risk of death from cardiovascular causes or any cause in general.
The study yielded the following findings:
- Approximately 33.4% of adults diagnosed with Type 2 diabetes exhibited elevated levels of the two protein markers, indicating undetected cardiovascular disease. In comparison, only 16.1% of individuals without diabetes showed similar signs.
- Among adults with Type 2 diabetes, elevated levels of troponin and N-terminal pro-B-type natriuretic peptide were linked to a higher risk of all-cause death (increased risk of 77% and 78%, respectively) and cardiovascular death (more than double the increased risk and 54% increased risk, respectively), compared to individuals with normal levels of these proteins. The elevated risk persisted even after adjusting for other cardiovascular risk factors.
- After adjusting for age, individuals with Type 2 diabetes exhibited a higher prevalence of elevated troponin levels across various categories such as age, sex, race/ethnicity, and weight. On the other hand, when age was taken into account, there was no significant elevation in N-terminal pro-B-type natriuretic peptide levels in individuals with Type 2 diabetes compared to those without diabetes.
- The prevalence of elevated troponin levels was notably higher in individuals with Type 2 diabetes who had a longer duration of the condition and poorly controlled blood sugar levels.
In the context of reducing the risk of cardiovascular disease in individuals with Type 2 diabetes, cholesterol is commonly targeted. However, it is important to recognize that Type 2 diabetes can have a direct impact on the heart that is not necessarily linked to cholesterol levels. Elizabeth Selvin, one of the researchers involved in the study, emphasized this point, stating that if Type 2 diabetes is causing harm to the small vessels in the heart independently of cholesterol plaque buildup, then cholesterol-lowering medications alone may not be sufficient to prevent cardiac damage.
The research findings suggest that additional therapeutic approaches beyond statin medications are required to effectively lower the risk of cardiovascular disease in individuals with Type 2 diabetes. These non-statin-related therapies would address the specific mechanisms through which Type 2 diabetes impacts the heart, going beyond cholesterol management.
Extensive research has explored the impact of conventional risk factors like high blood pressure and cholesterol on cardiovascular health. Nevertheless, recent evidence indicates the need to include screening for specific cardiac biomarkers in routine assessments of traditional cardiovascular risk factors.
"The biomarkers examined in this study possess significant potency in systematically classifying individuals according to their health condition. Integrating regular biomarker measurements into practice could assist in directing cardiovascular prevention therapies towards individuals with Type 2 diabetes who face a heightened risk," she further explained.
This study stands out as one of the initial investigations utilizing participants that accurately represent the general population. However, due to the limitations of the available data in terms of identifying specific cardiovascular events such as heart disease, heart failure, stroke, or other complications, further research is necessary. Additional studies are required to determine if incorporating routine measurements of these biomarkers can effectively decrease the occurrence of cardiovascular complications within this specific population.
According to the American Heart Association’s 2023 Statistical Update, 102,188 U.S. deaths in 2020 were attributed to diabetes (including Type 1 and Type 2 diabetes) and an estimated 1.64 million deaths globally.
Co-authors are Michael Fang, Ph.D., M.H.S.; Dan Wang, M.S.; Olive Tang, M.D., Ph.D., M.H.S.; John William McEvoy, M.B., B.Ch., B.A.O., M.H.S., M.Ed., Ph.D.; Justin B. Echouffo-Tcheugui, M.D., Ph.D.; and Robert H. Christenson, Ph.D. Authors’ disclosures are listed in the manuscript.
The study was funded by the Biomarkers Consortium of the Foundation for the National Institutes of Health.
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