What is the Patient Support Program for T2DM patients about? What are the drivers to initiate this in Hong Kong and what are the objectives of the program?
The Patient Support Program (PSP) is an initiative to support diabetes mellitus (DM) patients to conduct a full DM complication assessment (DMCA). The patients’ results are collected with consent and reviewed at the end of the program as second objective.
This PSP is a local, single-center, open-label study. It generates some local data on NT-proBNP profile in an unselected random sample of type 2 diabetes mellitus (T2DM) patients in HK. It included 240 T2DM patients from both public and private sectors. Among T2DM patients without NT-proBNP and DMCA done in the past year, the prevalence of patients with an elevated risk of heart failure and cardiovascular disease was assessed by NT-proBNP.
What learnings have you gained thus far from this program and its effectiveness in your clinical practice?
Even though enrolled patients are relatively young, overweight, and well controlled in blood glucose, blood pressure and low-density lipoprotein (LDL), still, there are around 10% of patients that have NT-proBNP level >125pg/mL – a cutoff indicating an increased risk of future cardiac events, and requiring closer monitoring, lifestyle modification and/or treatment intensification.
Similar to some other international cohort studies, the main use of NT-proBNP assay serves as a comfortable 85-90% rule-out tool which could reassure the subjects on overall cardiac health with a simple, safe and affordable blood test and advised the subjects to repeat yearly for continuous reassurance.
Why is NT-proBNP used for the Patient Support Program?
Cardiac events & heart failure are the leading causes of hospital admissions and death among patients with diabetes. Heart failure is a heterogeneous and multifactorial disease so the prediction of risk for new-onset heart failure is challenging. Moreover, early heart failure is asymptomatic and difficult to identify among T2DM patients even with multiple risk factors. For instance, the traditional 8 high risk factors – age, smoking, BMI, HbA1c level, hypertension, serum lipids, poor renal function and family cardiovascular (CV) history – are less predictive of heart failure.
Recent literatures suggest NT-proBNP is a better predictor of heart failure risk in T2DM patients with multiple CV risk factors.
From an endocrinologist’s perspective, what is the value of NT-proBNP as a CVD risk stratification tool for T2DM patients?
From my perspective, 2 groups of T2DM patients are advisable to have an NT-proBNP measurement together with an annual DMCA: those already with multiple CV risks and those health-conscious patients.
NT-proBNP may be used as an additional screening tool during DMCA to identify T2DM patients who may develop macro-vascular complications in the short to medium term. It may enhance CV risk stratification and facilitate the introduction or optimization of proven cardio-protective drugs in patients without a known history of CVD.
For those mildly elevated groups (NT-proBNP around 125 to 300 pg/mL), we may just simply review their clinical profiles. If the value is rather predictable based on age, sex, renal function, and clinical history, I will optimize possible lifestyle change and related drug usage; and reassessed clinically with a follow up NT-proBNP measurement three to six months later.
For those very high and unexpected cases, I will suggest patients to consider further investigations (eg. Holter, Echocardiogram, CTCA, etc.) or initiate a cardiac referral to identify possible type and aetiology of underlying heart failure condition.
What is the unmet need in existing routine assessment and should NT-proBNP be part of this?
Our traditional DMCA which includes blood tests (CBC, renal and liver functions, urate, HbA1c, lipid profile); urine test (albuminuria); retinal assessment, and feet at risk assessments (neuropathy and peripheral vascular disease) – is good for prediction of microvascular disease but rather suboptimal for early alert of risk for macrovascular CV complications. Early identification of T2DM patients with high CV risk during annual DMCA may help to improve subsequent patient outcomes.
Hence, there is a clinical need to have a simple, safe, evidence-based and affordable tool to enhance CV risk prediction in our T2DM patients.
Now, I would include an annual NT-proBNP for those T2DM patients with significant CV risks or those worrying about cardiac health during the time of performing a DMCA.
