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.