Spotlight on CVD risk prediction

One study found that wider diabetes screening made a cardiovascular disease (CVD) prediction tool less accurate, while other research evaluated the ability of coronary artery calcium testing and a neuropathy questionnaire to identify type 2 diabetes patients with high CVD risk.

Multiple recent studies looked at the challenge of accurately assessing cardiovascular disease (CVD) risk among patients with type 2 diabetes.

The first study, published by The Lancet on June 2, analyzed how widespread diabetes screening affected CVD risk prediction in New Zealand, where efforts in recent years have succeeded in screening 90% of the eligible population for diabetes. It included 46,652 people with type 2 diabetes who were ages 30 to 74 years and free of CVD, heart failure, or substantial renal impairment at baseline. A total of 4,114 experienced a first cardiovascular event during approximately five years of follow-up. A much higher event rate would have been predicted by the equation typically used to estimate CVD risk in diabetes in New Zealand (threefold higher in women, doubled in men), the study found. The authors concluded that “recent widespread diabetes screening has radically changed the cardiovascular risk profile of people with diabetes in New Zealand” and warned of “international implications as increased diabetes screening is inevitable due to increasing obesity, simpler screening tests, and the introduction of new-generation glucose-lowering medications that prevent cardiovascular events.” They, as well as an accompanying commenter, called for more tailored risk prediction.

Another study, published by Diabetes Care on June 2, assessed the potential of repeated CT coronary artery calcium (CAC) testing to risk stratify people with and without type 2 diabetes. The study included 5,836 patients (618 with type 2 diabetes) from the Multi-Ethnic Study of Atherosclerosis and found that among 45-year-olds, 23% of those with type 2 diabetes were found to have CAC compared to 17% of those without diabetes. Median age at incident CAC was 52.2 years versus 62.3 years, respectively. Duration of diabetes, male sex, White race, hypertension, hypercholesterolemia, obesity, and low serum creatinine levels were also associated with the presence of CAC. “Our results show that the absolute risk of developing newly detectable CAC is much higher for patients with type 2 diabetes, especially for those with longer diabetes treatment duration,” the authors said. The authors noted that current guidelines support statins even for diabetes patients with a CAC score of 0, but they suggested that other, newer medications might eventually be targeted based on the information from CAC testing.

Finally, a study published by Diabetes Care on May 26 looked at the utility of the Michigan Neuropathy Screening Instrument questionnaire (MNSIq) for predicting CVD risk. The MNSIq was performed on 6,473 patients in two Danish studies, at diabetes diagnosis in one study and a median of 4.6 years after diagnosis in the other. A score of 4 or greater was considered indicative of diabetic polyneuropathy. Using the Danish national patient registry, the study assessed the incidence of CVD among the patients and found that those with MNSIq scores of 4 or greater had significantly higher CVD risk during follow-up (incidence rate ratio, 1.65 [95% CI, 1.41 to 1.95] versus a score <4). “The MNSIq may be a tool to identify a subgroup within individuals with newly diagnosed type 2 diabetes with a high incidence rate of subsequent CVD,” concluded the authors. They noted that the score may identify “markers of undefined mechanisms in the causal pathways of both [diabetic polyneuropathy] and CVD (e.g., physical activity level, obesity, cardiac, global vascular damage, or autonomic neuropathy)” and help clinicians target aggressive CVD screening and preventive therapies to the “individuals who stand to gain the most.”