NT-proBNP for Cardiovascular Risk Stratification in T2DM: From Evidence to Clinical Practice

This is a verbatim transcript of an interview conducted with Prof Ronald Ma in October 2025. The transcript has been lightly edited for clarity.

What is the current landscape for cardiovascular risk stratification in people with type 2 diabetes in HK/China, and which tools or markers show the most promise?

So there are different clinical risk equations that can be implemented for risk stratification for cardiovascular disease in people with diabetes. In Hong Kong, we have developed the JADE risk score using data from our local population and this is one form of a clinical risk score that we try to implement to stratify individuals at high risk of cardiovascular disease.

However, it is often difficult to try to implement or calculate risk score in a busy clinic if it’s not already incorporated into the clinical pathway, which is why having biomarkers that can be used in the clinic to identify those at high risk would be of great utility.

So in the Precision Medicine and Diabetes Initiative (PMDI), which was a global initiative with colleagues across the world, we had the opportunity to conduct a systematic review, trying to examine clinical risk scores and biomarkers that can facilitate risk stratification for cardiovascular disease risk in people with type two diabetes (T2DM). In that analysis, we looked at both risk scores as well as more than 300 biomarkers that has been reported to be associated with future risk of heart disease in people with diabetes.

In the analysis, we focus on prospective analysis looking at incident complications. And what we found was NT-proBNP was amongst the most consistent and had the strongest evidence as a promising biomarker for predicting the risk of cardiovascular disease in people with T2DM.

What is the predictive value of NT-proBNP for cardiovascular and renal outcomes in Asian patients with type 2 diabetes in real-world clinical settings?

So NT-proBNP has already been incorporated in different international guidelines for the identification of those at high risk for hospitalisation with congestive heart failure. And for example, it is already in guidelines issued by the American Diabetes Association as well as other guidelines.

But what we found from our systematic review in terms of NT-proBNP having utility to identify risk of cardiovascular disease, suggests that this marker actually may be useful not only for identifying those at risk of congestive heart failure, but also those with a broader spectrum of cardiovascular disease. And interestingly, also identify those at risk of renal disease.

So in our real world setting, we actually conduct a testing of NT-proBNP in baseline samples from around 2000 individuals of T2DM, where we followed up for median duration of over five years. Currently, from what we found was that baseline NT-proBNP was a strong predictor of subsequent risk of hospitalisation for heart failure. But interestingly, also subsequent development of cardiovascular disease, atrial fibrillation, and also various renal endpoints including 40% drop in eGFR as well as development of incident end stage renal failure, suggesting that NT-proBNP can be a useful marker in clinical practice to identify future cardiorenal risk among individuals with T2DM.

So what we also found was that in our own cohort analysis, using the biomarker alone performed better than using a clinical risk score for identifying those at risk of cardiovascular disease. This is actually similar to other studies that have been conducted in European populations, for example, where use of the biomarker alone outperform use of risk scores for predicting cardiovascular risk.

In fact, we found in our cohort that the performance of NT-proBNP had a C index of approximately 0.8 to 0.9 for most of the cardiorenal endpoints we examined, which meant that it had good utility in clinical practice to differentiate between those at high risk versus those at low risk. And this was most impressive and most consistent for congestive heart failure but was also actually impressive for identifying those for renal failure.

How can incorporating NT‑proBNP into routine diabetes care help improve patient outcomes? What changes can be implemented when a patient is identified as high-risk?

So we think that perhaps incorporation of NT-proBNP testing is most useful in individuals of Type 2 Diabetes who also have coexisting risk factors such as hypertension, hyperlipidemia or renal impairment. Identification of those who have elevated NT-proBNP should prompt a series of follow up actions. This should include optimisation of existing cardiovascular risk factors, including blood pressure and lipid control, and should also prompt clinicians to try to review the medications and consider for example, stopping drugs that may increase the risk of cardiovascular events such as congestive heart failure.

So for example, stopping TZDs and DPP-4 inhibitors. And also consider introducing cardioprotective treatment such as SGLT2 inhibitors and GLP-1 receptor agonists. So the testing actually facilitates precision medicine in diabetes by identifying those at risk precision prognostic as well as stratifying and tailoring treatment for that patient precision treatment. So this actually achieves a more individualised approach to patient management.

What more can be done to support wider adoption of NT‑proBNP testing in clinical practice across the region?

So I think one thing that we all have to think about is how to incorporate the testing into our current clinical care pathways to facilitate testing, interpretation of results, and also follow up action according to the results. So different healthcare settings will come up with different solutions.

So for example in Hong Kong, we have an annual or regular diabetes complication assessment where patients undergo a comprehensive battery of tests including checking the eyes, the kidney, microalbuminuria, lipids, etc. And for us, we are looking into how to incorporate NT‑proBNP into that pathway so that it would be done at the same time and then can be interpreted together with the other results.

I think different healthcare settings may need to think slightly differently according to how the care pathway is set up. And of course, cost is one consideration. However, we are conducting cost effective analysis for the Hong Kong setting, looking at the implications for NT‑proBNP testing and its impact on management and reduction of hospitalisation of with heart failure. And indeed, our analysis are promising and suggests that the testing can be cost effective and cost saving in some settings.

So in terms of actual implementation, I think incorporation into clinical care pathways is important. Education of both patients and healthcare professionals would be key to appreciate the importance and the clinical relevance. But importantly, what are the follow up actions needed after abnormal test.

So I think also this testing of NT‑proBNP brings up an important issue of how to enhance collaboration across different health discipline. So just like NT‑proBNP is a way of communication between the heart and kidney, also the testing of NT-proBNP should facilitate the dialogue between different health care professionals engaged in the management of people with diabetes, including the person living with diabetes, including the primary care physician, the endocrinologist, the cardiologist, and the nephrologists, for example.

So testing and demonstration of elevated NT-proBNP should prompt a series of different follow up actions as we discussed regarding modification of treatment, but also arranging of the appropriate investigations, which may include echocardiogram, and also planning of other investigations as appropriate. So this actually provides an excellent opportunity to bring in the different discipline to truly deliver multidisciplinary care for individualised care for the individual living with diabetes. Thank you.

The views and opinions expressed by Prof Ronald Ma are his own views and opinions. Roche disclaims all liability in relation to these views and opinions.