Response to Comment on Hillis et al. The Relative and Combined Ability of High-Sensitivity Cardiac Troponin T and N-Terminal Pro-B-Type Natriuretic Peptide to Predict Cardiovascular Events and Death in Patients With Type 2 Diabetes. Diabetes Care 2014;37:295–303

We are grateful to Neuhold et al. (1) for their interest in our article (2) and agree with their insightful comments. They highlight an interesting juxtaposition in the field of preventative medicine. While there is increasing disquiet being aired by many regarding the overdiagnosis and overtreatment of some conditions in developed countries, at the same time guidelines for the prevention of cardiovascular disease in the general populations of these countries are being considerably broadened.

Although there is ongoing debate about the extent to which patients with type 2 diabetes should automatically receive preventative treatments, such as high-dose potent statins, the arguments against “medicalization” are perhaps less relevant in this population. It is generally accepted that all adult patients with type 2 diabetes have some increased risk of cardiovascular complications but, as Neuhold et al. point out, there is considerable heterogeneity in the excess risk. Intuitively, it would be useful to better identify those at highest, and indeed lowest, risk. Currently, much money and effort is expended on expensive investigations, often with limited evidence that these improve outcome. Likewise, we remain uncertain as to which patients might derive particular benefits from specific interventions, such as more aggressive lipid or blood pressure lowering or from primary prevention with antiplatelet agents, and, also important, which patients will likely derive no benefit at all (or worse). Our data suggest that biomarkers such as NT-proBNP and high-sensitivity troponin might be useful tests, particularly to more accurately categorize patients who, on the basis of clinical assessment, are at intermediate risk. It is crucial, however, that future studies clarify whether and how this information could be used to individualize treatments more effectively, reduce health care costs, and improve outcomes. Promising early data (3) suggest that biomarkers, such as NT-proBNP, could be used in this way, but further work is required.