N-terminal pro B-type natriuretic peptide (NT-proBNP) is a well-established marker of myocardial stress and heart failure, but its value for predicting broader cardiovascular-kidney outcomes in multi-ethnic Asian populations with type 2 diabetes (T2D) remains unclear. This study aimed to compare the predictive performance of NT-proBNP with traditional biomarkers (high-sensitivity C-reactive protein, troponin-T, albuminuria, and HbA1c) for cardiovascular-kidney events and all-cause mortality in this population.

In this prospective, single-centre cohort study, adults (≥40 years) with T2D and no prior history of heart failure were enrolled and followed for up to 5 years. Baseline demographics, clinical characteristics, biomarker levels, laboratory results, electrocardiogram, and echocardiographic parameters were collected. This interim analysis included events within the first year. Association between NT-proBNP and a composite outcome [death, hospitalisation for heart failure (HHF), myocardial infarction, stroke, coronary revascularisation, and lower limb amputation or revascularisation) was assessed using logistic regression. The predictive value of NT-proBNP versus traditional biomarkers for composite outcome, all-cause mortality, 4-point major adverse cardiovascular events (MACE) (cardiovascular death, HHF, myocardial infarction, stroke), HHF, and kidney failure (eGFR <15 ml/min/1.73m², dialysis or transplantation) was evaluated using Cox regression and time-dependent receiver operating characteristic analyses. All biomarkers were log-transformed before analysis.

Of 1,200 participants [mean age 61.5 ± 9.3 years; 55.7% male; median diabetes duration 14 years (interquartile range, IQR 7-21)], 72.6% were Chinese, 16.2% Asian Indian, and 8.3% Malay. The median NT-proBNP level was 37.7 pg/ml (IQR 18.8-81.1), and 15.4% of participants had NT-proBNP ≥125 pg/ml. After one year, 42 cardiovascular events (including 6 HHF), 7 kidney failures, and 8 deaths were recorded. After adjusting for covariates, NT-proBNP was significantly associated with the composite outcome (HR 1.94; 95% CI 1.52-2.46). NT-proBNP and troponin-T showed superior discrimination for the composite outcome and 4-point MACE compared to other biomarkers (refer to Figure 1). NT-proBNP showed the highest predictive accuracy for all-cause mortality and HHF, while NT-proBNP, troponin-T, and albuminuria were strong predictors of kidney failure. The optimal NT-proBNP cut-off based on Youden’s index for predicting the composite outcome was 60.4 pg/ml (sensitivity 68.3%, specificity 66.6%).

NT-proBNP outperformed traditional biomarkers in predicting cardiovascular-kidney events and mortality in multi-ethnic Asian adults with T2D. These results support incorporating NT-proBNP into risk stratification protocols for improved clinical management.