FNIH-Funded Study Finds 1 Out of 3 US Adults with Type 2 Diabetes Has Undetected Cardiovascular Disease

One-third of US adults have undetected cardiovascular disease, marked by elevated levels of two proteins linked to heart damage.

It’s not exactly news that there’s a relationship between type 2 diabetes and cardiovascular disease (CVD). CVD results in almost 70% of deaths in people with type 2 diabetes. 1

But what if you learned that there was another important layer to this relationship that, until recently, was yet to be uncovered?

The discovery? About a third of American adults with type 2 diabetes may have undetected CVD. This and other findings were revealed in a recent study, published in the Journal of the American Heart Association (JAHA) and funded by the Foundation for the National Institutes of Health’s (FNIH) Biomarkers Consortium. The study set out to assess the number of American adults with undetected CVD by measuring specific cardiac biomarkers (substances in the body used to evaluate heart function).

The Cardiac Biomarkers Project

Cardiac biomarkers were the topic of investigation for the FNIH’s Biomarkers Consortium’s Cardiac Biomarkers Project. The project was an almost decade-long undertaking to address several gaps in the CVD field, such as defining “normal” reference ranges for selected cardiac biomarkers and generating the basis for their use for monitoring risk across diverse groups. This was done by measuring a panel of cardiac, kidney, and diabetes biomarkers—chosen for their strong potential to monitor CVD in the general population—in almost 25,000 individuals who participated in a national study, called the National Health and Nutrition Examination Survey (NHANES). Data gathered from the Cardiac Biomarkers Project is intended to inform US clinical and laboratory guidelines related to the use of these biomarkers. To date, the Cardiac Biomarkers Project has yielded more than two dozen manuscripts, with more in the works, as well as several high-profile editorials.

One unique hallmark of the Cardiac Biomarkers Project was its use of a population-based study sample with significant diversity. The researchers were able to expand knowledge around the prevalence of undetected CVD in the general adult US population, making the project highly generalizable and relevant for medical management.

“Because a population-based sample was used in the project, these data show significant and valuable differences to inform treatment across diverse populations. The project was executed with patience and persistence, making use of finite resources, and still yielding a wealth of actionable knowledge that will affect medical management of cardiovascular disease in the future.”

Tania Kamphaus

Director, Translational Science Metabolic Disorders and FNIH Director of Patient Engagement

Uncovering the Layers: Undetected CVD and Type 2 Diabetes

The JAHA study is a great example of meeting the goals of the Cardiac Biomarkers Project, especially as it relates to patients with diabetes.Led by Elizabeth Selvin, PhD, MPH, a professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health, the investigators set out to define undetected CVD in a representative sample of people. To achieve this goal, Dr. Selvin and her team used stored serum samples of over 10,000 adults who participated in NHANES to measure the presence of two biomarkers, high-sensitivity cardiac troponin (cardiac troponin) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), which indicate heart damage.“NHANES was specifically designed to provide the national data needed to define reference ranges for laboratory assays and to help establish screening and diagnostic cut-points in the US population. It is also the only national cohort with biospecimens that includes large numbers of diverse populations, including children, older adults, and racial and ethnic minorities,” Dr. Selvin explained.The major finding from this study was that approximately 1 in 3 adults in the US with diabetes had undetected CVD, as shown by high levels of the selected cardiac biomarkers (cardiac troponin and NT-proBNP). Undetected CVD is a significant condition because, though symptomless, it is a stepping stone to clinical CVD. The researchers also found that elevated cardiac troponin was significantly higher in those who had diabetes over longer periods and who had poorly controlled blood sugar levels. Finally, the researchers found that there were associations between high levels of both cardiac biomarkers and death from CVD and death due to any cause, even after adjusting for demographic and cardiovascular risk factors.These two cardiac biomarkers have provided a window into cardiovascular disease in people who otherwise might not be recognized as highest risk.

Dr. Selvin’s research also indicates that type 2 diabetes may be causing harm to the small vessels in the heart that may not be related to cholesterol plaque buildup. Therefore, cholesterol-lowering drugs alone may not be enough to prevent heart damage in this condition.

According to Dr. Selvin’s study, routine testing of cardiac biomarkers may indicate the need for preventive strategies for the highest‐risk patients with diabetes. And, those who have had a longer duration of diabetes or poor blood sugar control would benefit from intensive treatment, along with frequent CVD risk assessment. Dr. Selvin advises, “People who are identified to be at high risk for cardiovascular disease should receive aggressive management of risk factors such as blood pressure and lipids. Lifestyle interventions, including engaging in routine physical activity, are also critically important.”

Dr. Selvin credits the FNIH’s role in bringing together the stakeholders needed to make the study happen, remarking, “I have been fortunate to work with amazing people and lead epidemiologic studies that have directly influenced clinical guidelines.” She further stated, “Our series of manuscripts enabled by FNIH’s Cardiac Biomarkers Project provide novel evidence to support the use of these lab tests for routine risk monitoring in high-risk populations, such as persons with diabetes.”

1 American Diabetes Association. Diabetes Complications Cardiovascular Disease. 2023.

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