Contrary to public opinion, the main cause of death for people with diabetes is cardiovascular disease, explains endocrinologist Justin Echouffo Tcheugui.

“The popular belief is that people with diabetes die from renal disease, or eye disease,” says Tcheugui, whose practice focuses on patients with type 2 diabetes. “More than 60% of people with diabetes die because they have a cardiovascular complication, and one of these cardiovascular complications is heart failure.”

Processes unique to diabetes, and in tandem, obesity, can lead to adverse cardiac remodeling — structural and functional changes to the heart caused by inflammation or production of substances such as glucose that, in excess, become toxic, he says. Abnormal metabolism in the heart compounds the problem. The American Diabetes Association recommends screening for cardiac dysfunction in people with diabetes, followed by imaging to assess cardiac damage.

But there has been little data on the risk of heart failure and its subtypes related to type 2 diabetes among people with elevated cardiac biomarkers — a subject Tcheugui and colleagues sleuthed out in a study published early this year in Diabetes Care.

Researchers leveraged the medical data from 3,484 participants in the Jackson Heart Study, a prospective cohort study of Black adults ages 21 to 94 living in Mississippi. They compared baseline characteristics of the participants based on their diabetes status, subclinical myocardial injury and/or stress status. In cross sectional analyses, they explored the relationship between these factors and echocardiographic parameters. In longitudinal analyses, they estimated the incidence rates of heart failure and its subtypes.

The prevalence of subclinical myocardial injury was 26.4% overall, but it was much higher among people with diabetes compared with those without diabetes (38.1% versus 23.1%, respectively).

Across diabetes categories, people with subclinical myocardial injury tended to be older and exhibit higher body-mass index and lower physical activity levels. They also tended to have higher rates of hypertension and coronary artery disease compared with those without subclinical myocardial injury.

The incidence of heart failure was highest among participants with diabetes and subclinical myocardial injury or stress. People with diabetes and subclinical myocardial injury had about a 10-fold higher crude incidence rate of heart failure compared with those who did not have the two conditions. Similarly, those with diabetes and myocardial stress had a 12-fold higher absolute risk of heart failure compared with those who did not have the conditions.

At the time of study recruitment, participants with diabetes and subclinical myocardial injury were found to have a 3.8 times higher risk of developing heart failure, a 3.7-fold higher risk of heart failure with preserved ejection fraction and a 4.2-fold higher risk of heart failure with reduced ejection fraction, compared with people who did not have diabetes and subclinical myocardial injury. People with diabetes and subclinical myocardial stress also exhibited a four-fold higher risk of heart failure, compared with people who did not have these conditions.

“Our study has important implications for public health and clinical practice,” Tcheugui says. “It underscores the potential benefits of a more active detection of heart failure among individuals with diabetes.”

People with diabetes and elevated cardiac biomarkers could benefit from therapies such as use of sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists to reduce heart failure risk, he says. Lifestyle interventions such as increasing physical activity and making dietary changes also can be beneficial in this context. These approaches “may help curb the epidemic of heart failure among Black adults, who also experience very high rates of diabetes,” says Tcheugui.