Diabetes Core Update – Special Edition: Heart Failure Part 3 – Case-based Discussion

Podcast Date: March 11, 2025
Host: Dr. Neil Skolnick
Guests: Dr. Muthu Vaduganathan (Cardiologist), Dr. Susan Kucera (Family Medicine)

Main Theme and Purpose

This third installment in Diabetes Core Update’s Heart Failure Special Edition turns from recommendations and treatment of Heart Failure with Preserved Ejection Fraction (HFpEF) to applied clinical judgment through real cases, focusing on earlier detection, nuanced risk assessment, and patient-centered management. The episode features an open, practical discussion led by experts, highlighting uncertainties and evolving best practices in HFpEF, especially in patients with diabetes—a growing focus of both research and real-world primary care.

Key Discussion Points & Insights

1. Early Screening and Staging in Diabetes Care

[00:02–06:55]

• Screening Recommendations:
  New ADA Standards encourage natriuretic peptide (BNP, NT-proBNP) screening for heart failure in adults with diabetes, aiming to identify early, asymptomatic disease (Stage B)—those with cardiac changes but no overt symptoms.
• Heart Failure Stages Recap:
  • Stage A: At-risk (risk factors only).
  • Stage B: Cardiac structural or functional abnormality, no symptoms.
  • Stage C: Symptomatic, “clinical” heart failure (approx. 6 million Americans).
  • Stage D: Advanced heart failure (~1–2% of group).

Quote:
“Can we identify an earlier stage of disease that precedes the symptomatic phase, that we can actually deploy potentially effective interventions to prevent the symptomatic onset of heart failure?”
—Dr. Muthu Vaduganathan [04:02]

2. Case 1: Middle-aged Woman with Nonspecific Symptoms

[06:55–15:07]

• Scenario: 57-year-old woman, hypertension, obesity, fatigue/"out of shape," minor dyspnea, normal exam.
• Primary Care Dilemma: These vague presentations are common. It's challenging to know when to dig deeper.
• Evolving Practice:
  Dr. Kucera describes expanding routine panels (CBC, CMP, TSH) to include BNP—a simple step to catch more subclinical cases.
• Symptom Overlap with Everyday Life:
  Many over-50s have NYHA Class II symptoms (fatigue, mild dyspnea on exertion); careful quantification and looking for progression is essential.

Quote:
“It’s really hard to know when to pursue this and look for something more. This is a tough call in primary care… now that we can screen for heart failure so easily by adding a blood test... it’s become a lot easier to screen.”
—Dr. Susan Kucera [06:55]

• Role of NT-proBNP:
  • Age, body habitus (notably obesity lowers it), and comorbidities affect interpretation.
  • Ambulatory cutoff: 125 pg/mL—far lower than the acute thresholds commonly recalled.

Quote:
“The universal definition of heart failure has simplified things… 125 picograms per milliliter is a single cutoff in this type of ambulatory care.”
—Dr. Muthu Vaduganathan [13:17]

3. Diagnosis & Counseling after Abnormal Echo

[15:07–17:19]

• Echo shows: Normal EF (55–60%), diastolic dysfunction, no valve disease.
• Patient Communication:
  Explaining “heart failure” to patients not in crisis needs new approaches. Frame early detection as good news, providing time and options for risk modification.
• Treatment Nuances:
  Focused, patient-centered decisions on medications (e.g., SGLT2 inhibitors, MRAs, GLP-1 agonists), and lifestyle interventions.

Quote:
“There are lots and lots of medicines now that have data to help slow down the progression of this… I think it just really depends on where that patient sitting in front of you is at because there’s, you know, lots of right answers here.”
—Dr. Susan Kucera [15:07]

4. Contemporary Treatment Landscape for HFpEF

[17:19–22:20]

• Strongest Evidence:
  • SGLT2 inhibitors and non-steroidal MRAs (finerenone) are “foundational.”
  • GLP-1 agonists, ARNI, and ARBs are considered based on individual needs (obesity, degree and type of heart failure, presence of congestion).
• Flexible Approach:
  Unlike HFrEF (where all patients should get four pillars), HFpEF therapy must be layered, responsive to risk, and patient context.

Quote:
“We have the strongest evidence for the SGLT2 inhibitors and the nonsteroidal mineralocorticoid receptor antagonist finerenone. Those are drugs that we have definitive clinical outcome trial data with large, well-executed global trials.”
—Dr. Muthu Vaduganathan [18:21]

5. Case 2: Post-hospitalization, Higher Risk Elderly Male

[22:20–28:28]

• Scenario: 72-year-old, multiple risk factors, recent HFpEF hospitalization, currently on loop diuretic, amlodipine, optimal diabetes control.
• Urgency & Medication Optimization:
  • Rapid adjustment required: Shift BP control away from amlodipine (little HFpEF data), switch from metformin to agents benefiting both DM and HF, minimize chronic NSAID use.
• Therapies Modify Outcomes Quickly:
  • SGLT2 inhibitors & finerenone show benefits (statistically significant) within as little as one month from initiation.

Quote:
“The curves separated so rapidly that you saw first statistical significance on the primary endpoints within just one month of initiation.”
—Dr. Muthu Vaduganathan [26:52]

6. Integrating Cardiology and Primary Care in Early and Late HFpEF

[28:28–30:54]

• Changing Patterns:
  As more HFpEF is found earlier, primary care teams take on a larger role. But involvement of cardiology—early for difficult, high-risk, or progressing cases—is increasingly important.
• Referral Triggers:
  • After hospitalization
  • Recurring/rapidly escalating symptoms
  • Progressive need for diuretic adjustments

Quote:
“Cardiologists should be a central part of the management of HFpEF, and we should become involved very early in this process… after a hospitalization, clearly, that should be an indication for referral.”
—Dr. Muthu Vaduganathan [29:50]

Notable Quotes & Memorable Moments

• “We are in a new era of HFpEF… just a few years ago we had limited tools… now, in a few short years, we are in a new era.”
  —Dr. Muthu Vaduganathan [31:54]

• “We’re going to be finding and diagnosing a lot more heart failure with preserved ejection fraction. So I think this is a really critical update and well timed.”
  —Dr. Susan Kucera [31:34]

Highlighted Segment Timestamps

• Early Screening and Stages in Diabetes: [00:02–06:55]
• Case 1: Primary Care Decision Points: [06:55–15:07]
• NT-proBNP, Cutoffs, and Obesity Discussion: [11:05–14:10]
• Treatment Choices – SGLT2s, MRAs, GLP-1s: [17:19–22:20]
• Case 2: Acute/Transition Care, Therapy Initiation: [22:20–28:28]
• Guidance on Cardiology Collaboration/Referrals: [28:28–30:54]
• Final Reflections / State of the Field: [31:34–32:35]

Concluding Thoughts

This episode underscores the expanding prevalence and complexity of HFpEF, especially as screening becomes routine in diabetes care. The panel encourages a balanced, individualized approach—embracing new therapies, rapid risk modification after hospitalization, and nuanced, honest patient communication. With abundant evidence and more robust trial data for therapies like SGLT2 inhibitors and finerenone, clinicians are empowered to intervene earlier and more effectively, but also must navigate uncertainties and tailor care to each patient's journey.

The future will rely on close primary care–cardiology collaboration, ongoing updates from emerging research, and proactive identification and engagement of patients at every stage of HFpEF.