Suboptimal cardioprotective medication prescribing in patients with diabetes and stage B heart failure

Background

Individuals with diabetes often have structural and functional cardiac abnormalities before development of heart failure symptoms (Stage B HF). Trials in type 2 diabetes (T2D) and stage B HF show that prescribing and optimisation of renin-angiotensin-aldosterone inhibitors (RAASi) and beta-blockers to target doses (TD) can improve outcomes and reduce the risk of symptomatic heart failure and is now recommended in cardiology and diabetes guidelines. HF develops earlier and frequently in type 1 diabetes (T1D), with worse outcomes. Guideline Directed Medical Therapy (GDMT) implementation and dose optimisation in T1D with stage B HF has not been studied.

Purpose

To examine the use and prescribing patterns of RAASi and beta-blockers in T1D individuals with stage B HF and compare to T2D individuals.

Methods

We included T1D individuals (n=434) with NTProBNP measured in Tayside, Scotland (population~450,000) between Oct 2020–Feb 2026. After excluding prior HF, medical history and prescribing details were collected from electronic health records. An age/sex-matched T2D cohort (insulin users and non-users) without HF and with NTProBNP measured was also included. Prescription and dosage of RAASi and beta-blockers was evaluated. The dosage was recorded as percentage TD as per ESC guidelines. Multivariable logistic regression identified predictors of RAASi and beta-blocker use.

Results

434 T1D individuals had NTProBNP measured (mean age 56 years, 56.2% male). Excluding 21 with HF prior to NTProBNP testing, a final cohort of 413 individuals (median NTProBNP [IM1.1]89.5pg/mL (IQR=[IM2.1]39.0, 201.7) remained. 78 (19%) had NTProBNP >125 pg/mL. Compared to an age/sex-matched T2D cohort (58 on insulin and 96 on diet/oral), T1Ds were more likely to have prior MI (39.7% vs 19.8%, p=0.01) and CKD[IM3.1] (28.2% vs 13.5%, p=0.009).

Prescribing rates were similar for T1D vs T2D diet/oral and T2D insulin groups (Beta-blockers: 43.6% vs 40.6% and 46.6%, p=0.77; RAASi: 52.6% vs 60.4% and 60.3%, p=0.52). RAASi optimisation was particularly low in T1D: 26.9% achieved ≥50% TD vs 48.2% (T2D diet/oral, p=0.004) and 44.8% (T2D insulin, p=0.032). At 100% TD, rates were 14.1% vs 24.0%/32.8% (p=0.09/0.01). Beta-blocker prescribing was low in all groups, ≥50% TD was similar between all groups. At 100% TD, T1D lagged vs T2D diet/oral (2.6% vs 8.3%, p=0.01).

Predictors of ≥50% RAASi dose were hypertension (p<0.001) and no prior MI (p=0.002). Predictors of ≥50% beta-blocker dose included prior MI, AF, higher weight and male sex (all p<0.05).

Conclusion

In this cohort almost 20% of T1D individuals without prior HF had NTProBNP levels >125 pg/mL indicative of stage B HF. Prescribing of RAASi and beta-blockers was extremely low in both T1D and T2D. T1D individuals were significantly less likely to be on optimal RAASi doses compared to T2D. These data highlight that better strategies are needed to identify Stage B HF and optimize GDMT in T1D.100% of Individuals Achieving Target Dose50% of Individuals Achieving Target Dose