Exertional breathlessness, reduced exercise tolerance and ankle swelling in an older person with long-standing type 2 diabetes are easily put down to weight, deconditioning or age. Heart failure with preserved ejection fraction is common in exactly this group, and a normal-looking ejection fraction on an old echo does not exclude it.
A natriuretic peptide is the usual first test: a low value makes heart failure unlikely, while a raised one warrants echocardiography. Interpret it with care in obesity, where levels run lower, and in kidney disease and atrial fibrillation, where they run higher.
- Ask about breathlessness on exertion, orthopnoea and ankle swelling at the annual diabetes review.
- Obesity lowers natriuretic peptide levels, so a borderline value in a heavy patient deserves more weight.
- Chronic kidney disease and atrial fibrillation raise natriuretic peptide levels independently of heart failure.
- A heart failure diagnosis strengthens the case for an SGLT2 inhibitor, whatever the HbA1c.
Why it matters
Symptoms of preserved-ejection-fraction heart failure are routinely attributed to weight or age in people with diabetes.
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