Conventional cardiovascular risk assessments may overestimate risk in populations with widespread diabetes screening guidelines

1. Widespread diabetes screening helps to identify asymptomatic patients with preserved renal function and low diabetes-associated cardiovascular risk.

2. New cardiovascular risk stratification strategies are needed given heterogeneous characteristics of patients with type 2 diabetes. 

Evidence Rating Level: 2 (Good) 

Study Rundown: In the last decade, New Zealand Ministry of Health has implemented universal diabetes and cardiovascular risk assessments. The 2019 PREDICT cohort trial captures primary care outcomes after implementation of these screening measures. After the implementation of widespread diabetes screening, the Framingham equation, previously recommended to estimate cardiovascular risk, was shown inadequately estimate risk for individuals with type 2 diabetes. This retrospective cohort study utilizes diabetes-specific outcomes from the PREDICT cohort to improve on the New Zealand Diabetes Cohort Study (NZDCS) specific risk assessment equation. The primary outcomes for cardiovascular risk included ischemic heart disease, cerebrovascular events, and congestive heart failure. Variables included for risk assessment were age, years since diabetes diagnosis, smoking status, HbA1c, renal function, and use of cardiovascular or diabetes drugs. The results of this study provide an improved risk stratification equation, PREDICT-1 Diabetes equation, that better differentiates low-risk from high-risk individuals tailored for those with a diabetes diagnosis. These findings may affect the pharmacologic and non-pharmacologic management of patients with diabetes to optimize their cardiovascular health.

Click to read the study in The Lancet

Relevant Reading: Cardiovascular disease risk prediction equations in 400 000 primary care patients in New Zealand: a derivation and validation study

In-Depth [retrospective cohort]: This study included 46,625 individuals from the PREDICT type 2 diabetes subcohort, all of whom did not have known cardiovascular disease, heart failure, or substantial renal impairment at time of enrollment. The PREDICT-1 Diabetes equation was developed for sex-specific prediction of first cardiovascular event based on a range of pre-specified variables using a Cox multivariable regression model with linear fit for the majority of factors. The equation was validated by comparing 5-year predicted risk with observed 5-year risk of cardiovascular events, which showed strong calibration of predicted and observed risk especially when compared to the previously recommended NZDCS equation. In the context of widespread screening, the PREDICT-1 equation enables risk stratification of an evolving patient population with largely preserved renal function not currently on glucose-lowering medications, also incorporating sociodemographic information in risk assessment. The limitations of this study center on the relatively narrow New Zealand population and care within a standardized, national healthcare system, limiting applicability of findings to global care settings. Despite this limitation, identifies the need to reassess and adjust risk prediction equations to match the evolving patient population diagnosed with type 2 diabetes. The improved cardiovascular risk assessment offered by the PREDICT-1 trial will help practitioners better identify high-risk patients who would benefit from cardioprotective pharmacotherapy, preventing overtreatment and encouraging more cost-effective care.

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