Introduction
Hello I am Dr. Ameya Joshi. I am consultant in charge of endocrinology at Bhaktivedanta Hospital and Research Institute as well as Endocrine and Diabetes Clinic Mumbai.
In your opinion, why is regular HF screening with NT-proBNP among patients with stable T2DM in OPD critical?
The most important complication in people with diabetes is actually cardiovascular disease. The clinicians used to think in terms of myocardial infection (MI) as well as stroke when the thought of cardiovascular disease. Over a period of time, we realized that the commonest complication of cardiovascular disease in people with T2DM is actually HF, a complication that could be affecting as much as 22% of people with T2DM. A complication that changes the prognosis of people with T2DM, making them more vulnerable for repeated hospitalizations due to HF, unless proper guideline based therapy is initiated as early as possible. And so, the paradigm is now shifting as the growing burden of HF among T2DM patients is being recognized and needs urgent action. The American Diabetes Association (ADA), in its position paper in 2022, routed for screening for HF among individuals with T2DM with risk factors for HF. In 2024, the ADA Standards of Care statement includes screening for HF in people with diabetes by using NT-proBNP or BNP as the biomarkers. European Society of Cardiology (ESC) guidelines also endorse use of NT-proBNP as a screening test for evaluating risk of HF. With all these facts in sight, I think it’s high time to critically consider regular HF screening with NT-proBNP among patients with T2DM who are stable and attending the outpatient departments.
Please tell us about the real world study you recently conducted to screen T2DM patients for cardiovascular disease.
The prevalence of T2DM in our society is increasing and people are living longer. So the burden of complications of diabetes is increasing. And so, the prevalence of HF is also bound to go up. In fact, it is already high and also the treatment of T2DM is defined by presence or absence of HF, or the increased or decreased risk of HF in a particular subject. With this in mind and with the position paper from the ADA in 2022, we started screening our outpatient department, attending people with T2DM, who had came for elective consultation by using NT-proBNP as a biomarker, and we thought that since we are doing it, we should also audit this practice, that how many come positive for HF screening and also follow up those who have came positive for HF, and also try to identify which subset of people with T2DM are at risk of HF. So we decided to audit our data and we had screen approximately 1049 people with T2DM for NT-proBNP who were attending the (internal) medicine and endocrinology outpatient departments. The subjects were in the age group of 18 to 75 years, and all these subjects never had any ischemic heart disease or HF in the past, they’ve never had any cardiac ailment. They had normal ECG and then they were screened for NT-proBNP. All those were abnormal ECGs, cardiac arrhythmias, prior HF, chronic kidney or liver diseases, respiratory failure, infection, malignancy, pregnancy, were excluded from this study. We also recorded the demographic variables like vitals, smoking status, family history, hypertension status, glycemic control and correlated it with risk of screen positivity for HF. The screening for HF was done using NT-proBNP and we used a cutoff of 125 pg/mL to label someone screen positive. Subjects who were found to be screen positive for HF, were referred to the cardiology department and underwent 2D echocardiography stress test or a coronary calcium scoring as deemed fit by a cardiologist, and the therapeutic changes were made as per the guidelines that were directed and the patients were followed up.
Why did you embark on this study?
Picking up HF in people with T2DM is crucial, and picking it up early is very relevant. We know those who are at risk of HF, that’s stage A, and we know the symptoms of HF, that’s stage C and stage D of symptomatic HF. But can we do something to identify those who are at risk, who are progressing to stage C and stage D? And there comes the role of a biomarker, a positivity of which means that a person at risk is progressing to a symptomatic stage. If the treatment is initiated in a correct manner, morbidity and mortality can be reduced. The scoring systems used in the past have fell short of it, and so an objective tool such as NT-proBNP biomarker can be well utilized for effective screening of our T2DM patients in our setting to understand the risk of HF. And rightly so, in our study, we found that 336 out of 1049 patients with T2DM screen positive for HF, amounting to a prevalence of 32% in the population. These patients would have been missed without screening, and as an endocrinologist, this helped me classify this subset differently and choose anti-diabetic medications accordingly.
In your study, what were the significant characteristics of the screen positive patients (NT-proBNP >125pg/mL)? Why is that important?
Now let me discuss the subset of T2DM population which was vulnerable to HF or at more risk of being diagnosed as screen positive for HF. And the factors that determine the positivity was the median age, the duration of diabetes, the presence of smoking or tobacco chewing as habits, a higher heart rate, a raised blood pressure, a raised total cholesterol and LDL level, higher BMI, a raised glycated hemoglobin (HbA1c) which were significantly associated with screen positivity for HF. Similarly, people with chronic kidney disease and T2DM were much more likely to be screen positive for HF. We observed almost equal prevalence in both genders. However, family history as a risk factor is highlighted in our study, which is missed in most of the scoring systems. Indians are vulnerable to early onset heart disease and it can occur earlier in the subsequent generations. Hence, the need to look for family history as a risk factor for heart disease. This information gives clinicians an idea about various population subgroups who are at high risk for screen positivity, and so screening for HF can be more proactively pursued in these subgroups.
How can this study help physicians incorporate early HF screening for their patients with T2DM during routine OPD follow ups?
It is crucial, compelling, and relevant to include screening for HF for risk certification in routine diabetes care. However, this is not yet a common practice. The accuracy of HF diagnosis, assessment of severity, and prediction of adverse events have much improved with the use of objective biomarkers such as NT-proBNP. Its clinical utility can be very well utilized by general physicians, diabetologists and endocrinologists for the better standard of care for T2DM. More number of people with T2DM can benefit for guideline directed medical therapy for prevention of HF hospitalisations. The T2DM patients with risk factors can be screened regularly during their OPD consultation. As recognized by various guidelines, the screening with NT-proBNP can be repeated annually. Besides providing the objective assessment of risk of HF, it can also be used as an effective patient education tool for explaining the cardiovascular risk to the patient and counseling them for compliance, as well as the need to stick to the correct treatment.
