Is Screening for Heart Failure and Peripheral Artery Disease Warranted in Asymptomatic Adults With Diabetes? A Perspective on the 2025 American Diabetes Association “Standards of Care in Diabetes”

Abstract

The American Diabetes Association (ADA) publishes the “Standards of Care in Diabetes” (SOC) annually to offer clinicians, patients, and payers evidence-based guidelines for diabetes management. The 2025 SOC recommends that clinicians consider screening asymptomatic adults with diabetes for heart failure using natriuretic peptide levels, and that they screen asymptomatic adults with diabetes ≥65 years of age with any microvascular disease, foot complications, or end-organ damage from diabetes for peripheral artery disease (PAD) using ankle-brachial index (ABI) testing. This perspective evaluates those recommendations using established screening principles and the published literature. The recommendation to screen for heart failure using natriuretic peptide lacks robust evidence in several key areas. N-terminal pro-B-type natriuretic peptide, or NT-proBNP, itself performs poorly as a screening test in asymptomatic adults. Furthermore, there is ambiguity in treatment recommendations and insufficient evidence showing improved outcomes with sodium–glucose cotransporter 2 inhibitor treatment in adults with diabetes and stage B heart failure. Finally, the costs involved are high and may not be economically justifiable. Similarly, the recommendation to screen for PAD in asymptomatic adults with diabetes is not backed by rigorous scientific evidence. The evidence cited combines ABI screening with other effective screening tests and has limited generalizability. There is no guidance on how to interpret the results of ABI testing or how the information gained should be used to direct treatment. While the intent to improve health care through screening is commendable, these recommendations are inadequately supported by the principles of screening and the published literature. It is imperative that the ADA uses the greatest scientific rigor to prepare its SOC.

Graphical Abstract

Introduction

The American Diabetes Association (ADA) publishes the “Standards of Care in Diabetes” (SOC) to provide clinicians, patients, and payers evidence-based guidelines for diabetes care (1). The SOC is prepared by the ADA Professional Practice Committee and reviewed and approved by the ADA Board of Directors. The SOC, which appears each year as a supplement to the January issue of Diabetes Care, is the sole source of official ADA clinical practice recommendations. Since 2018, the ADA has updated and revised the online version of SOC throughout the year, making it a living document. Over time, the SOC has grown in scope and complexity, increasing from only 4 pages in 1989 (2) to 352 pages in 2025 (3). Although the ADA publishes consensus reports (analyses, evaluations, and opinions authored by ad hoc expert panels) and scientific reviews (in-depth reviews and analyses of the literature on scientific or medical topics related to diabetes), neither represents official positions of the ADA.

In 2025, the SOC recommended that clinicians consider screening adults with diabetes by measuring a natriuretic peptide to facilitate prevention of stage C heart failure (Fig. 1) (4). A second recommendation was to screen asymptomatic individuals with diabetes and age ≥65 years, microvascular disease in any location, or foot complications or any end-organ damage from diabetes for peripheral artery disease (PAD) with ankle-brachial index (ABI) testing if a PAD diagnosis would change management (Fig. 1) (4). Because of the importance of the ADA SOC for clinical care and policy, and because both recommendations involved screening asymptomatic individuals, we felt it was important to carefully weigh the evidence supporting these recommendations.

Figure 1.

2025 ADA SOC recommendations for screening for cardiovascular disease. Reprinted from “Standards of Care in Diabetes—2025” (4).

In 1968, Wilson and Jungner (5) defined screening as “The presumptive identification of unrecognized disease … by the application of tests, examinations, or other procedures which can be applied rapidly. Screening tests sort out apparently well persons who probably have a disease from those who probably do not. A screening test is not intended to be diagnostic. Persons with positive or suspicious findings must be referred… for diagnosis and necessary treatment.” Ten principles were recommended to assess whether screening is an appropriate course of action to improve health. These principles, as edited by Dobrow et al. (6), are shown in Table 1. They continue to be used widely to evaluate the benefits, harms, costs, and ethics of screening programs. We will critique the ADA’s recent screening recommendations according to these principles and the published literature.

Table 1.

Wilson and Jungner’s principles of screening

No.	Principle
1.	The condition sought should be an important health problem.
2.	The natural history of the condition, including development from latent to declared disease, should be adequately understood.
3.	There should be a recognizable latent or early symptomatic stage.
4.	There should be a suitable test or examination.
5.	The test should be acceptable to the population.
6.	There should be an agreed-upon policy on whom to treat as patients.
7.	There should be an accepted treatment for patients with recognized disease.
8.	Facilities for diagnosis and treatment should be available.
9.	The cost of case finding (including a diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.
10.	Case finding should be a continuous process and not a “once and for all” project.

Adapted from Dobrow et al. (6).

Screening for Heart Failure

The recommendations to screen for heart failure in the 2025 SOC are shown in Fig. 1 (4). Five of the criteria for screening listed in Table 1 do not appear to be met by this recommendation. These include that 1) the natural history of asymptomatic heart failure be understood, 2) there be a suitable screening test, 3) there be an agreed-upon policy about whom and when to treat, 4) there be a proven-effective treatment for patients with asymptomatic stage B heart failure, and 5) the benefits and costs of screening, diagnosis, and treatment be balanced with possible harms and expenditures for medical care as a whole.

The 2024 SOC defines stage A heart failure as a state of increased risk for heart failure without symptoms, biomarker evidence of myocardial strain, or structural heart disease (7). All adults with diabetes are considered to have stage A heart failure on the basis of having diabetes. Stage B heart failure is defined as being asymptomatic but having evidence of structural heart disease or functional cardiac abnormalities, including elevated biomarkers of myocardial strain or increased filling pressures (7). Stage C and stage D heart failure are defined as progressively severe states of symptomatic heart failure.

The most important measures of the performance of a screening test are the positive predictive value (PPV), or the probability that an individual with a positive screening test has the disease, and the negative predictive value (NPV), or the probability that an individual with a negative screening test is free of the disease. The PPV and NPV depend on the sensitivity and specificity of the screening test and the prevalence of the condition in the population. The SOC identified the N-terminal pro-B-type natriuretic peptide (NT-proBNP) as the preferred screening test and defined the threshold for an abnormal test as ≥125 pg/mL. We will therefore focus on this test.

The performance of NT-proBNP as a screening test has been assessed in a study of a U.K. primary care population (8), a study of patients with acute onset of dyspnea presenting to 19 North American emergency departments (9), and an individual patient–level meta-analysis of two European prospective studies of patients with symptoms and signs of heart failure (10).

In the U.K. primary care study, natriuretic peptide testing was initially recommended to aid decision-making when the diagnosis of heart failure was uncertain and subsequently when patients presented with symptoms suggestive of heart failure (8). Nearly 230,000 adults ≥45 years of age were screened between 2004 and 2018. Mean age was 61 years, 25% of the population had diabetes, and the prevalence of heart failure diagnosed within 6 months of screening was 9.2%. The use of NT-proBNP ≥125 pg/mL was 94.6% sensitive and 50.0% specific in diagnosing heart failure. The PPV was 16.4% and NPV was 98.9%. Thus, approximately 1 in 6 patients with a positive screening test had heart failure, and essentially all with negative screening tests did not have heart failure.

In the North American emergency department study, nearly 1,500 patients with acute dyspnea, defined as subjective feelings of shortness of breath, difficult breathing, or labored breathing, were studied (9). Mean age was 56 years, 29% of the population had diabetes, and 19% were adjudicated as having acute heart failure. The 125 pg/mL NT-proBNP cutoff was 96.7% sensitive and 61.4% specific for acute heart failure in the ∼1,300 patients <75 years of age. The PPV was 33.35% and NPV was 98.9%.

The individual patient-level meta-analysis combined data from two studies, one in the U.K. and the other in the Netherlands (10). Approximately 1,100 patients suspected of having new-onset heart failure on the basis of symptoms of lethargy (71%) and shortness of breath (87%) and signs of pulmonary rales (8%) and ankle edema (57%) were studied. Mean age was 72 years, 20% of the population had diabetes, and new-onset heart failure was diagnosed in 29% of participants. The use of NT-proBNP ≥125 pg/mL was 71.5% sensitive and 74.7% specific for diagnosing heart failure. The PPV was 56.2% and NPV was 85.1%.

The prevalence of heart failure in the primary care setting (9%) was substantially lower than that among people with acute onset of breathlessness (19%) or symptoms and signs of heart failure (29%). Accordingly, the prevalence of heart failure (9%) and the PPV of NT-proBNP as a screening test in an entirely asymptomatic population with type 2 diabetes would likely be more similar to that observed in the U.K. primary care screening population (16%) than that among symptomatic individuals, where PPV has been reported to be as high as 50% or even 60% (9). The implications of a low PPV for screening are that more individuals without disease are incorrectly labeled as being at risk for stage B heart failure (false-positive screening tests), requiring further diagnostic evaluation and potentially unnecessary treatment.

Another issue relates to the associations among age, sex, genetic factors, and both cardiac and noncardiac disorders and natriuretic peptide levels (11). Advanced age, female sex, and genetic variants are associated with higher NT-proBNP levels, as are renal insufficiency (estimated glomerular filtration rate <60 mL/min/1.73 m²), arrythmias (especially atrial fibrillation), acute coronary syndromes, pulmonary hypertension, and right ventricular dysfunction (11). Anemia, hyperthyroidism, and sepsis are also associated with higher NT-proBNP levels (11). NT-proBNP levels are lower in Black individuals compared with White individuals and in subjects with obesity compared with subjects without obesity (11). In the absence of age, sex, and comorbidity-specific thresholds, these differences can cause false-positive and false-negative screening test results, unnecessary diagnostic evaluations and treatments, and missed opportunities to intervene.

A second criterion to maximize the benefits and minimize the harms of screening is a clear definition of whom to treat and when to treat. The SOC states that in asymptomatic individuals with diabetes and abnormal natriuretic peptide levels, echocardiography is recommended to identify stage B heart failure (4). Further guidance recommends “an interprofessional approach, which should include a cardiovascular disease specialist … to implement a guideline-directed medical treatment strategy” (4). Based on this guidance, it is unclear how the information from the NT-proBNP and echocardiogram should be integrated to inform treatment decisions by the diabetes care provider and the cardiologist. Whom, when, and how to treat are not explicitly addressed.

The third criterion to maximize the benefits and minimize the harms of screening is to have an accepted and proven-effective treatment or treatments. Treatments recommended for prevention of progression to symptomatic heart failure in people with diabetes and asymptomatic heart failure include lifestyle intervention with nutrition, physical activity, weight management, and smoking cessation; hypertension management; and the use of ACE inhibitors or angiotensin receptor blockers, β-blockers, and sodium–glucose cotransporter 2 (SGLT2) inhibitors (4,12).

It is not clear that the lifestyle intervention or blood pressure management recommendations differ from those for the general population with diabetes. The specific evidence cited to support the recommendations regarding the use of ACE inhibitors or angiotensin receptor blockers and β-blockers come from two clinical trials (4,7). The first is the St Vincent’s Screening to Prevent Heart Failure (STOP-HF) study randomized trial (13). It sought to determine the efficacy of a screening program using BNP and a collaborative treatment model to reduce left ventricular systolic and/or diastolic dysfunction and/or newly diagnosed heart failure. Nearly 1,400 subjects with cardiovascular risk factors were recruited from 39 primary care practices in Ireland between 2005 and 2009 and followed for a median of 4.2 years. At baseline, mean age was 65 years and 20% of the subjects had diabetes. Subjects were randomly assigned to receive usual primary care or screening with BNP. Individuals who were screened and found to have elevated BNP levels underwent echocardiography and collaborative care provided by both primary care physicians and a specialist cardiovascular service. The screening and intervention group received more renin-angiotensin-aldosterone system–based therapy than the control group (57% vs. 50%, P = 0.01). The primary end point of left ventricular dysfunction with or without heart failure was significantly reduced in the screening and intervention group compared with the control group over 4 years (5.3% vs. 8.7%, odds ratio 0.55, P = 0.003), but among participants with abnormal BNP, the incidence of heart failure was not significantly reduced (1.0% vs. 2.1%, odds ratio 0.48, P = 0.12).

The second study, NT-proBNP Guided Primary Prevention of CV Events in Diabetic Patients (PONTIAC), was a prospective randomized controlled trial conducted in Austria between 2007 and 2010. It involved 300 patients with type 2 diabetes and elevated NT-proBNP levels who were otherwise free of cardiac disease based on history, electrocardiogram, and echocardiography (with the exception of allowing participants to have evidence of diastolic dysfunction) (14). Initially, 2,189 patients were screened for eligibility, 1,479 (68%) did not meet inclusion criteria, and 410 (19%) declined to participate. A total of 300 patients (14%) were randomly assigned to an intensified treatment group that was treated at a cardiac outpatient clinic for uptitration of renin-angiotensin system antagonists and β-blockers or a control treatment group that was cared for at four diabetes care units. The primary end point was hospitalization or death due to cardiac disease. Secondary end points were all-cause hospitalizations, unplanned cardiovascular hospitalization or death, heart failure hospitalizations, and changes in NT-proBNP levels after 1 year. At baseline, mean age was 68 years and mean duration of diabetes was 15 years. HbA_1c was 7% and systolic blood pressure was 151 mmHg. At 12 months, patients receiving more intensified treatment were more likely to be treated with renin-angiotensin antagonists and β-blockers than control patients (95% and 85% vs. 78% and 44%, respectively, both P = 0.0001). Blood pressure was significantly reduced in both groups. There was a significant reduction in the primary end point of hospitalization or death due to cardiac disease (hazard ratio [HR] 0.35, P = 0.04), the secondary outcomes of all-cause hospitalizations (HR 0.66, P = 0.02), and unplanned cardiovascular hospitalizations or death (HR 0.38, P = 0.03). There was no significant reduction in heart failure hospitalizations (HR 0.14, P = 0.07). Interestingly, treatment was not associated with changes in NT-proBNP, and the authors concluded that although NT-proBNP may be a good marker of risk, more research is needed to determine if it can be used as a biomarker to guide treatment.

Evidence that the use of SGLT2 inhibitors delays progression from asymptomatic stage B heart failure to symptomatic heart failure in people with type 2 diabetes is also lacking. The SOC cites the BI 10773 (Empagliflozin) Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME) trial (15), the Canagliflozin Cardiovascular Assessment Study (CANVAS) program (16), and the Dapagliflozin Effect on Cardiovascular Events trial (DECLARE-TIMI 58) (17) as evidence. In those studies, 10%, 14%, and 10% of study participants, respectively, had histories of heart failure at baseline. In EMPA-REG, rates of hospitalization for heart failure were 4.1% with placebo treatment and 2.7% with empagliflozin treatment over a median follow-up of 3.1 years. In DECLARE-TIMI 58, rates of hospitalization for heart failure were 3.3% with placebo treatment and 2.5% with dapagliflozin treatment over a median follow-up of 4.2 years. Although the reductions in the relative risks of hospitalization for heart failure in the EMPA-REG, CANVAS, and DECLARE-TIMI 58 studies were large (35%, 33%, and 27%, respectively), the proportions of all three study populations having histories of heart failure at baseline were greater than the proportions hospitalized for heart failure during follow-up, and the absolute risk reductions of hospitalization for heart failure (1.4 percentage points over 3.1 years in the EMPA-REG trial and 0.8 percentage points over 4.2 years in the DECLARE-TIMI 58 trial) were small. In addition, none of the studies specifically studied asymptomatic patients with abnormal natriuretic peptide levels with or without abnormalities on echocardiography. The recommendation to treat patients with type 2 diabetes and asymptomatic stage B heart failure with SGLT2 inhibitors is thus not directly supported by the evidence from those randomized clinical trials, the absolute risk reduction is likely to be small, and the numbers needed to treat to prevent one case of symptomatic heart failure is likely to be large.

The final criterion to maximize the benefits of screening relates to the potential harms and costs of case finding and treatment. In terms of anxiety and quality of life, the impact of labeling all patients with diabetes as having stage A heart failure and of labeling otherwise asymptomatic patients with elevated natriuretic peptide levels, with or without abnormal echocardiograms, as having stage B heart failure is unknown.

In addition, the costs of case finding and the recommended treatment are substantial despite unclear benefits. According to the 2024 Medicare Fee Schedule, reimbursement for screening with BNP or NT-proBNP is $39.26 per test (CPT code 83880). Medicare reimbursement for an echocardiogram ranges from $98.53 for a limited study (CPT code 93308) to $221.03 for a complete echocardiogram with spectral Doppler examination (CPT codes 93306 and 93321). The 2024 Medicare reimbursement rate for a moderate-complexity new patient visit with a cardiologist is $132.15 (CPT code 99204), and that for each moderate-complexity return visit is $96.20 (CPT code 99214). According to the 2025 ADA SOC, the median National Average Drug Acquisition Cost for empagliflozin is $586 per month (18).

Conservatively estimating that 700 asymptomatic people with type 2 diabetes would need to be screened once to identify 100 people with elevated NT-proBNP levels (PPV ∼14%), that all 100 with elevated NT-proBNP levels would require echocardiograms and an initial visit with a cardiologist for definitive diagnosis and treatment planning, and that half of them would require SGLT2 inhibitor treatment and annual follow-up visits with a cardiologist for 4 years to prevent one hospitalization for heart failure based on the results of the STOP-HF trial (13), the cost of screening and treatment would be $1,482,315 to prevent one hospitalization for heart failure (Table 2). Ninety-five percent of the cost would be associated with SGLT2 inhibitor treatment.

Table 2.

Estimated cost of screening, managing, and treating asymptomatic patients with type 2 diabetes and stage B heart failure to prevent one hospitalization for heart failure over 4 years

Test	Number of patients	Unit cost	Total cost
NT-proBNP	700	$39.26	$27,482
Echocardiogram*	100	$159.78	$15,978
Interprofessional management	100	$132.15 per NP × 4 years
With CVD specialist†		$96.20 per RV × 4 years	$32,455
SGLT2 inhibitor**	50	$586 per month × 48 months	$1,406,400
Total			$1,482,315

CVD, cardiovascular disease; NP, new patient visit; RV, return visit.

*Estimated as average cost of a limited echocardiogram and a complete echocardiogram with spectral Doppler examination.

†Estimated as average cost of a moderate-complexity new patient visit followed by annual moderate-complexity return visits.

**Median National Average Drug Acquisition Cost for empagliflozin is used.

A generic SGLT2 inhibitor (dapagliflozin) was recently approved in the U.S. (19) at an average manufacturer price ∼39% lower than the brand-name price (20). Despite this, the additional cost of screening, management, and treatment to prevent one hospitalization for heart failure remains ∼$934,000. Beyond the need for echocardiograms, cardiologist referrals, and SGLT2 inhibitors, clinical care for patients with elevated NT-proBNP levels might involve discontinuation of treatments, such as antihypertensive therapies, and other medications that might cause heart failure, such as thiazolidinediones. It is unlikely, however, that these potential cost-savings would have a major impact on total health care costs. Thus, at either SGLT2 inhibitor price, the estimated cost of screening, evaluating, and treating asymptomatic patients with type 2 diabetes and stage B heart failure over 4 years to prevent one hospitalization for symptomatic heart failure would not provide good value for the money.

Screening for PAD

The 2025 SOC also recommended screening for PAD “in asymptomatic individuals with diabetes and age ≥65 years, microvascular disease in any location, or foot complications or any end-organ damage from diabetes … if a PAD diagnosis would change management (B)” (Fig. 1) (4). Four of the criteria for screening do not appear to be met by this recommendation (Table 1). These include that 1) the natural history of the condition be adequately understood, 2) there be a suitable screening test or examination, 3) there be an agreed-upon policy on whom to treat as patients, and 4) the benefits and the potential harms and costs of screening be balanced.

The evidence cited for this recommendation comes from the Viborg Vascular (VIVA) trial, a randomized controlled trial that compared screening for hypertension, abdominal aortic aneurysm, and PAD with no screening in 50,156 Danish men 65–75 years of age between 2008 and 2011 (21). The primary outcome was all-cause mortality assessed 4.4 years after randomization. Screening and subsequent intervention reduced the absolute risk of all-cause mortality by 6 per 1,000 person-years (95% CI 1–11 per 1,000 person-years) and the relative risk by 7% (95% CI of HR 0.88–0.98). No significant differences were observed between the groups in cardiovascular mortality or rates of surgery for PAD (21).

The first issue with the recommendation relates to the evidence supporting it. The relevance of the VIVA trial results to the screening of asymptomatic Americans ≥65 years of age with diabetes for PAD is questionable based on the sex (men only), population (Danish), and diabetes status (∼10% with diabetes) of the subjects studied in the VIVA trial (21). The trial also bundled two screening interventions with proven effectiveness (hypertension screening, U.S. Preventive Services Task Force [USPSTF] level A recommendation [22], and abdominal aortic aneurysm screening, USPSTF level B recommendation [23]) with ABI screening, which has been shown to have uncertain benefits (USPSTF level I [insufficient evidence] recommendation) (24,25). No randomized trials have specifically assessed whether screening asymptomatic adults with ABI reduces morbidity or mortality from cardiovascular disease or PAD (24,25). The American Heart Association and the American College of Cardiology have stated that in patients at increased risk of PAD (including those with diabetes), screening for PAD with the resting ABI is “reasonable” based on moderate-quality evidence from one or more nonrandomized studies (26), but an earlier expert analysis published by the American College of Cardiology pointed out that PAD is most often suspected on the basis of symptoms and signs, and the assumption that finding asymptomatic PAD will lead to interventions to lower cardiovascular risk is speculative (27).

Perhaps the best perspective on screening for PAD in people with diabetes comes from the U.K. National Institute of Health and Care Excellence (28). They concluded that all diagnostic tests for PAD are more valuable in the setting of suspected PAD based on symptoms and signs. They therefore recommended thorough clinical assessment including a careful history of claudication, inspection of the limb, palpation of pulses, and 10-g monofilament testing before performing additional diagnostic tests. They also reviewed the most accurate diagnostic tools for people with diabetes and suspected PAD and concluded that Doppler waveform analysis may be superior to ABI for assessing PAD in people with diabetes (28).

A second issue relates to identifying an appropriate screening test. In the VIVA trial, an abnormal screening test for PAD was defined as an ABI <0.9 or at least 1.4. Patients with abnormal screening test results were diagnosed as having PAD on the basis of a repeat ABI measurement usually performed within a week. Other studies have recommended different screening cut points. The SOC remains silent as to appropriate cut points to define an abnormal test. In patients with diabetes or advanced chronic kidney disease, medial calcification may cause the infrapopliteal arteries at the ankle to become incompressible. In such patients, ABI is elevated, whereas in patients with restricted flow, ABI is reduced. Having both medial calcification and restricted flow may result in a normal ABI in a patient with PAD (29). In addition, the SOC provides no information about recommended downstream diagnostic testing for patients with abnormal screening test results. These might include Doppler waveform testing, computed tomography angiography, magnetic resonance angiography, or invasive angiography. Each of these tests is associated with potential harms and costs.

The third issue with the recommendation relates to the benefits of treatment. Treatment of people with PAD has two potential benefits: preventing cardiovascular events and reducing morbidity and mortality from lower-limb ischemia. Interventions to prevent cardiovascular disease include diet; physical activity; weight loss; managing glycemia, blood pressure, and lipid levels; smoking cessation; and antiplatelet therapy. The ADA already provides detailed recommendations for each of these interventions, which can be implemented without performing ABI testing in asymptomatic adults (3). Similarly, recommendations to reduce morbidity and mortality from lower-limb ischemia all focus on treating patients with symptoms and signs and are not dependent on screening for and diagnosing PAD in asymptomatic individuals (30).

Finally, the recommendation fails to address the potential harms of downstream diagnostic testing and the costs of screening and definitive diagnosis. Screening itself may increase anxiety, and follow-up diagnostic testing has potential harms and costs. In 2024, Medicare reimbursed $88.36 for ABI testing (CPT code 93922) (31), but under National Coverage Policy A57593 (32), Medicare does not pay for peripheral artery studies for asymptomatic patients. Medicare only reimburses for ABI testing when submitted with an ICD-10-CM code supporting its medical necessity. For these reasons, we believe that using ABI to screen asymptomatic adults with diabetes to diagnose PAD may produce anxiety and physical harms, will consume health care resources, and may not meaningfully impact treatment or outcomes.

Conclusions

Although the value of screening may seem intuitive and the availability of new and effective medications for the treatment of cardiovascular disease offers great promise, professional organizations that write clinical practice guidelines must adhere to the principles of screening and carefully consider the best available evidence related to the benefits, harms, and costs of screening. In addition, they should explicitly link their recommendations to program monitoring, evaluation, and reporting to ensure that the objectives of the recommendations are achieved (6). For the reasons cited above, we believe that the ADA’s recent recommendation to consider screening adults with diabetes for asymptomatic stage B heart failure is not currently supported by rigorous scientific evidence and incurs substantial cost. Similarly, we believe that the recommendation to screen asymptomatic adults with diabetes ≥65 years of age and any microvascular disease, foot complications, or end-organ damage for PAD using ABI is not supported by the evidence, has substantial costs, and is not warranted based on any potential benefits associated with diagnosis and treatment. The ADA SOC provides an authoritative source of evidence for diabetes care. It is therefore imperative that the ADA Professional Practice Committee critically examines the scientific evidence before making sweeping recommendations for screening and treatment.

Funding Statement

W.H.H. has received support from the Michigan Diabetes Research Center (NIH P30 DK020572) and the Michigan Center for Diabetes Translational Research (NIH P30 DK092926).