Screening for occult heart failure in type 2 diabetes: Evidence from India

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Guest Speaker: Ameya Joshi, MD - Endocrinologist and Diabetologist, Endocrine and Diabetes Clinic in Borivali West, Mumbai

This is an analysis of our data, real-world evidence. It is a cross-sectional study, and we zeroed down on a sample size which was needed — 264 — but we have data for 1,049 patients. So there’s a very little margin of error. We included those people who never had a cardiac event and had a normal ECG in an outpatient setting, excluding those who had pregnancy, arrhythmias, prior heart failure, prior CVD, CKD with eGFR below 16, chronic liver disease, or any terminally ill patient — those were excluded.

We recorded demographics for all, body mass index and other variables: HbA1c, lipid profile, renal function tests, which were done within the hospital. Those who screened positive, we offered them a cardiac evaluation and followed these patients up. Over the course of time, we will reveal how we have been doing, but we found out that 2D ECHO had a lot of heterogeneous readings, and we wanted to rule out this change. So, we extended coronary calcium scoring to at least those who were willing for it, and we found that also quite helpful. To our surprise, I agree this is data from a tertiary care centre, and obviously it is a screening out-of-pocket, so maybe there was a little bias — but we got a 32% positivity. That means 32% of our people had NT-proBNP above 125 pg/mL, confirming that they screened positive for heart failure.

Now, coming to what determined the positivity were: longer duration of diabetes, smokers had much more positivity, but more so tobacco chewing, which is a common practice in India and a few other countries that I know, was more strongly associated with screening positive for heart failure than smoking.

When we come to other factors, we realised that uncontrolled hypertension and higher heart rate, particularly uncontrolled systolic blood pressure, correlated better with screening positive for heart failure. A raised LDL level was significantly associated, as was raised body mass index (BMI) and a raised AGP event. We strongly feel that family history should be a determining factor. Those who had a family history screened positive 10 to 15 years earlier as compared to their genetics before they got an event, and those who had CKD had a much higher risk of getting screened positive for heart failure.

Let me take you through the relevance of these parameters for screening positive. Each year of increasing age increases the risk of having heart failure by 9%. Each year of increase in diabetes duration increases the odds of screen positivity by 1%. A one millimetre of mercury rise in systolic blood pressure increases the chances of screen positivity by 7%. CKD had much higher positivity rates. Smokers had much higher positivity rates. And those with a family history of heart failure or a cardiac event had much higher positivity rates.

So basically, we were able to know that in our population, which is attending the OPD with a normal ECG, who never had heart disease, there was a huge burden of heart failure. The risk factors — smoking, CKD, family history, uncontrolled blood pressure — were the factors where we should proactively discuss screening or insist on screening, even if cost is a limiting factor.

The strength is that it is real-world evidence from India. The limitation is that it is tertiary care sector data, so maybe positivity was a bit higher. And basically, it was an open-ended offer to screen all within a price, so maybe there was some bias in screening, but still the numbers are huge, and what is important is that screening should be offered to all, especially to those who deserve it. 

Our data is published, at least the initial analysis, in the Cureus journal. I will also allude to the follow-up and would like to invite opinions from others if they are doing things differently.

A cardiology referral usually means an echocardiography. We found a lot of heterogeneity, so we also emphasised on those who were willing to get a coronary calcium score. We will be presenting this at IDF, with a poster where we zeroed down on the utility of CSC in tandem with NT-proBNP to detect significant ischaemia.

Ischaemia stabilisation also improves NT-proBNP, that is one thing we realised. An endocrinologist looks to reduce BMI, give guideline-directed therapy, also treat obesity, consider pharmacotherapy, give dietary counselling, rule out sleep apnoea. We are also looking at renin levels.

We did coronary calcium scoring for a good number of patients and realized that at least two-thirds had a significant coronary calcium score. This is a simple checklist, for the sake of homogeneity, we all follow, whenever somebody screens positive: we do ischaemia screening, look at direct training screening, maintain haemoglobin above 11, maintain good glycaemic control, encourage weight reduction, target heart rate and BP more aggressively, look at thyroid function, and also look at albuminuria and direct targeted therapies — all of which we found helpful over a period of time.

One of the common questions is: “what after getting screened positive for heart failure?” And these are the few answers we got. We follow up every three months and ensure that NT-proBNP is normalized. Once it is stable, we follow these patients six-monthly with NT-proBNP, like we do for HbA1c and microalbuminuria.

What our study adds is real-world evidence from India, which is very strong? It helps to identify risk factors, so screening should be universal, but more emphasis should be given to those with risk factors. The language that helped us pass on screening to more patients came from this real-world evidence, which let us to convincingly tell our patients, “please, get screened” — this is what we have realized.

Occult heart failure is common in Indian diabetic populations. It may be significantly prevalent even with a normal ECG and 2D ECHO. The chances of heart failure increase with age, longer duration of diabetes, positive family history, smoking or tobacco chewing, presence of CKD, and uncontrolled hypertension. Occult ischaemia screening can be an important exercise in helping manage heart failure better. Recognition of heart failure and type 2 diabetes can have important therapeutic and prognostic implications, and we strongly recommend proactive screening for all, especially for those with risk enhancers.

I would also like to thank my colleagues, and thank you, Team Roche, for giving me the opportunity.