Implementation of CVD risk assessment in people with diabetes in India

Transcript from the talk: Cardiovascular disease (CVD) risk assessment in T2D - Implementation in a private hospital in India. 

Dr. Sanjay Kalra.

“I am an endocrinologist. We deal with hormones. And, you know, there are hormones, which help you with learning as well - dopamine, serotonin, these are some examples. So for the past 1 hr at least my dopamine has been on fire, learning new things about CV risk assessment. But there are other hormones as well. Not all hormones are happy like dopamine or serotonin, there are some hormones, which can be maladaptive, and one of them is NT-proBNP - something that we have been speaking about today. Let me talk about my practice. I work in a private hospital in India. Now you see, when you read the American guidelines you would tend to assume that everybody with diabetes is very well-behaved, they are all chronic patients, so they come in when diabetes is diagnosed, they stick around to the same health care system, like in Ireland, or perhaps the same health care provider as well, and they behave very well throughout life. As of course diabetes progresses as they become more and more mature, they become older, they need more medications, more treatment, more investigations as well. But where I work, some of our patients are chronic, others are acute. So we have a relatively higher percentage of patients with symptoms. The symptoms may be of hyperglycemia, they may be of complications, such as atherosclerotic cardiovascular disease or heart failure. And accordingly, our management changes. There is something known as Maslow's Hierarchy of needs. This comes from Maslow, who was a behavioural psychologist. So what he said is that at the very outset, everyone needs food, clothing, shelter, basic needs for survival. Once you have got those then you are moving on to search for love and affection, a sense of belonging, and after that you search out for self-esteem. For example, if you are not doing well in practice, you haven't got your degree or your fellowship, you are not going to dream of becoming the president of the ADA. That is something that comes to your mind only after you have gone through the basics of this pyramid. The same thing happens in diabetes as well. Some of our patients come in with very basic needs, they just need symptomatic control. And like I said, a relatively larger percent of our patients are like that in India. Once you have taken care of the symptoms, then they want gluco-metabolic control. They will say :”Doc, my HbA1c is 7.1, why don't you bring it down to 6.4?” If you have done that, then it is only after that that they will say, “Can you help me prevent heart disease, can you help me prevent kidney disease?” So as you evolve in this Maslowian hierarchy of diabetes needs, you tend to rely more and more upon investigations, so that you can predict the future and you can pre-empt the future. This is what we have been trying to do with NT-proBNP. In countries like India, we have multiple challenges and one of the challenges is speaking the same language with our patients. We have 800+ languages, every 50km the language and the food changes and I serve a group of patients who speak maybe 7-8 different dialects, 3-4 different languages. So to communicate the same thing to them in different languages, can be challenging and it helps us a lot if we have one single number that we can convey and that is the good thing about NT-proBNP, you can use numbers, and you can use concepts from Indian philosophy to help convey. 

Patients will ask you why do I need one more test, as it is, you are doing so many tests for me. Now in India and perhaps in other countries, a lot of people like predicting their future, they go to astrology to get their future predicted, so of course we have songs which tell us that during COVID, all our astrologists went on leave, nobody dared to predict the future while COVID was going on. We tell our patients that we have something called “medical astrology” or “biomarker astrology”. Whether you are born a capricorn, or venus, or aries, that may or may not predict your personality, no comments on that, but some biomarkers like NT-proBNP or hormones like NT-proBNP can actually predict your medical future, they can tell you the risk of future CV events. When you convey this to the patient, the patient actually feels very happy. You can empower your patients by telling him or her that a simple number is all you need to remember, you don't need to get into the complexities of what the heart does and what the hormones do. Another concept we use from our philosophy is that of karma. Now karma is an English word, it is present in all the English dictionaries. In Indian languages like Sanskrit and Hindi, karma can be past tense, present tense, and future tense. Karma is what we did yesterday, supposing I did not take care of my glucose, that influences my today, it influences my state of health today, it is like glycemic memory, glycemic legacy or metabolic memory. So, we use the word metabolic karma, you can also use the word cardiovascular karma. No point in crying over spilt milk, but you tell your patient that if you have an NT-proBNP today of lets say 125 or 250 or 600, that is your karma today. But we can take action, if we can know where we are standing today, we can prevent bad karma from happening tomorrow. So this is a very proactive approach from our philosophy. We use this concept to talk about BNP baggage, whatever baggage , whatever weight you are carrying of NT-proBNP, that can be lightened. You can share the bad karma today and you can achieve a happier karma tomorrow. There are people however, in a grey zone, so in my practice I tend to use the number 100 more frequently, because it is much easier to remember, much easier to remind your patients about, as compared to 125. But still NT-proBNP is a very simple, very sensible method of helping us communicate risk with our patients. We tell them that if the NT-proBNP is more than 125, we should become more aggressive in mitigation. I can do it myself, I can use the SGLT2 inhibitors, I can go for guideline-based therapy, or I might wish to refer to a cardiologist. If it is between 100 and 125, we should re-test early, maybe within six months, depending on symptoms. And below 100 then you can kind of relax, you are in good karma, in a safe zone. 

The most important people in my hospital for conveying this message are the phlebotomists and the diabetes educators. They use these concepts of medical astrology, of medical karma, metabolic karma, and they are able to communicate these concepts and these numbers in a very non-threatening manner, in a very salutogenic, “salus” means health in latin, in a very salutogenic manner to our patients. And my paramedical staff are indispensable, without them I will not be able to work, I would not be able to handle all the load that I have to. We use many concepts in our laboratory, these are examples of some pictures that we use, some charts that we have in the hospital. We talk about heartbreak, it is not the emotional kind of heartbreak, it is the endocrine, or cardiovascular heartbreak that you can have if you have heart failure. Some numbers are better if they are bigger, but other numbers are better if they are less, like NT-proBNP. And we talk about speed as well - there is a difference between speed and velocity, too much speed can be dangerous for your life when you are driving. NT-proBNP means that your heart is working a little bit harder than it should, so it might get tired, lets bring it back to normal. We have Dr. Ameya with us here today and recently one of his abstracts has been accepted in EASD. He screened 318 patients asymptomatic, and he found that 120 of them had an elevated NT-proBNP, that is 37.5%. We do the same in our practice, and we find that the NT-proBNP number helps us in informing the patient, and in creating a situation where shared decisions can be taken. In my practice, roughly 15% of all asymptomatic patients have high NT-proBNP and we refer all our high risk patients to the neighbouring cardiology centre. And there 50% of their patients, asymptomatic ones, have a high NT-proBNP. The very fact that we were able to deduce this number helps in telling the patient whether he should stick with us or whether we should involve a cardiologist. And it is not just about informed decision making, a shared decision making, between the patient, his or her caregiver, and myself, we also involve the cardiology team in this. 

VAT is something you are all familiar with, I remember going to Ireland once and they put lots and lots of VAT on whatever shopping I had done. VAT=Value Added Tax, but NT-proBNP is different, it is Value Added Therapy, so it actually adds a lot of value in our treatment of type-2 diabetes. It helps us become better at preventive diabetology, we are able to prevent disease, prevent disability and we are actually able to reduce costs. So that is what I like about this heart hormone. In endocrinology, we say that dopamine and serotonin are happy hormones, NT-proBNP is not a happy hormone, but that is wrong actually, if you use NT-proBNP in the right manner, it will make your patients happier, because you will be able to prevent them from getting into trouble. Thanks.”