Dr Sim: There is no clear guideline, especially in the Asian setting like, after X number of years of diabetes, we should start doing NT-proBNP. The traditional way of treating diabetes is just checking on HbA1c, and then wait till the patient develops coronary artery disease or heart failure. Then treatment initiated is with a usual statin, aspirin and heart failure medication, which may be a bit too late because, at that stage, the patient would be at stage C heart failure.
A paradigm shift in thinking is required to catch stage A and stage B heart failure in these diabetes patients. A biomarker NT-proBNP is an interesting way of looking at it. Hence the ADOPT trial is embarked upon in the APAC region. In the ADOPT trial, diabetes patients without frank CV diseases are being observed with the use of NT-proBNP. The patients with a raised NT-proBNP are a sicker group of patients, with a higher risk of future events. The study is trying to prove that the use of SGLT2 inhibitor and the upregulation of RAAS inhibition and beta-blocker in this group of patients may help reduce the risk of future events.
Dr Januzzi: Another study is the PONTIAC study, which has the exact same design, with NT-proBNP being greater than 125 pg/mL, intensification of therapy versus usual care in Diabetes patients.
In the CANVAS study, the baseline NT-proBNP value among patients both with and without prior heart failure was recorded. It showed that there was a substantial overlap between the two groups. A substantial percentage of patients in CANVAS probably had stage B heart failure but did not realise it, these are patients with diabetes for an average of 5 years and cardiac risk factors. When the CANVAS outcomes are perceived, these are outcomes as a function of 125 pg/mL, the same cut-offs used in ADOPT and in PONTIAC. It was observed that patients above 125 pg/mL had a risk for hospitalised heart failure more than five times compared to those patients with an NT-proBNP below 125 pg/mL. This is a very important finding lending support to the ACC/AHA recommendation to screen patients with diabetes. Hence, the recommendation is to measure in patients with diabetes and risk for cardiovascular events.
