Use ‘more precise’ CVD risk scores to target therapy intensity for people with diabetes
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Key takeaways:
- Diabetes is not a CVD risk equivalent, making an accurate CV risk assessment critical.
- Newer risk scores like PREVENT include diabetes-specific factors for more precise estimation.
Composite CVD risk factor control for U.S. adults with type 2 diabetes remains poor, but clinicians can use newer risk scores to better assess patients and prevent CV events with targeted therapies, according to a speaker.
Diabetes remains a global epidemic and the burden of disease is expected to reach more than 12% by 2045, Nathan D. Wong, PhD, MPH, FACC, FAHA, FNLA, MASPC, professor and director of the Heart Disease Prevention Program at the University of California, Irvine, and past president of the American Society for Preventive Cardiology, said during a presentation at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. CVD events are the most predominant outcome for people with diabetes, Wong said. Data show peripheral artery disease and heart failure are the most common first manifestations of CVD for people with diabetes, followed by angina and nonfatal myocardial infarction.
Diabetes is no longer considered a CVD risk equivalent; however, data show there are several predictors for CVD among adults with diabetes, Wong said. These include an HbA1c of 7% or higher, diabetes duration of 10 years or more or diabetes medication use, he said. Women, white adults, people aged 55 years and younger and those with high triglycerides or kidney disease are also at greater risk for CVD with a diabetes diagnosis compared with people without diabetes and CVD, Wong said.
“Diabetes should no longer be considered a risk equivalent per se, but it really emphasizes the importance of CV risk assessment in this population to target the intensity of therapy and motivate patients and physicians better,” Wong said.
Scores to estimate ASCVD risk
Wong noted that there are several available scores to estimate atherosclerotic CVD risk in diabetes and some may be more precise than others. The American Diabetes Association recommends the ASCVD risk estimator, which enables health care providers and patients to estimate 10-year and lifetime risks for ASCVD based on the pooled cohort equations and lifetime risk prediction tools.
“But it is important to point out that here, diabetes is just considered a binary factor,” Wong said. “We do not have some of the additional diabetes-specific factors, such as duration of diabetes or HbA1c, like what is present in the UKPDS risk score.”
Several new risk calculators have been introduced this year to help clinicians more precisely gauge CV risk for people with diabetes. One is the European SCORE2-Diabetes risk calculator, with a new algorithm that extends the existing SCORE2 risk calculator used across Europe since 2021. The new algorithm factors in age at diabetes diagnosis, HbA1c and estimated glomerular filtration rate, Wong said.
In November, the American Heart Association unveiled new PREVENT equations to evaluate 10- and 30-year absolute risk associated with cardiovascular-kidney-metabolic (CKM) syndrome. The PREVENT equations were developed using real-world contemporary datasets including more than 6 million adults and includes HF risk in addition to risk for MI and stroke. They omit race from CVD clinical care algorithms; include kidney function on top of traditional CVD risk factors for heart disease; and include components such as social determinants of health, blood glucose and kidney function, when clinically available.
“With this new CKM syndrome concept, what you can see is the equations include the usual predictors but now add in kidney function,” Wong said. “There are supplementary scores that can incorporate HbA1c and albumin-to-creatinine ratio as well as social determinants of health, which none of the prior risk scores have adequately incorporated. This is an important advance and we look forward to its implementation in clinical practice.”
Wong and colleagues have also developed a pooled cohort U.S. diabetes risk score that is currently under review.
Research also suggests that a coronary artery calcium (CAC) score could also help discern risk for CVD among people with diabetes, Wong said. Data show a tenfold variation in CHD event risk for people with a CAC score of 0 vs. 400 or higher.
“We also see this in people with metabolic syndrome,” Wong said. “It supports the concept that assessing CAC is likely to be the most useful of the current approaches to improving risk assessment in intermediate-risk people. And I will also add diabetes to that.”
Those with diabetes, short diabetes duration and zero calcification on CAC and should be considered fairly low risk, Wong said, noting that data show 90% of such patients remain free of CVD events at 10 years.
“If you have a longer duration of diabetes or an uncontrolled HbA1c, you have higher [CV] risk at all levels of coronary calcification,” Wong said.
Composite risk factor control key
In the U.S., individual CV risk factors such as HbA1c, blood pressure and LDL are “moderately” well controlled overall, Wong said; however, composite risk factor control for those three risk factors combined is very poor at approximately 15%.
“If you add nonsmoking status and [optimal] BMI, [control] is only at 8%,” Wong said. “Clearly, there is a disconnect. Some people are focusing more on HbA1c and perhaps forgetting about these other risk factors.”
Data from several large studies show that aggressive control of risk factors could prevent 55% of coronary heart disease events and that composite risk factor treatment to goal could prevent 38% of CHD events. Additionally, preliminary data suggest that adherence to multiple lifestyle factors may show greatest benefit when multiple health factors are at target, Wong said.
“The more lifestyle factors at control, the lower the risk [for CVD],” Wong said. “In fact, that risk reduction is accelerated further if you have multiple health factors at control. If your BMI, lipids, glucose and BP are at control, the additional benefit of health behaviors at control seem to be even greater, with as much as an 88% lower risk. That is a very important message.”
References:
- Khan SS, et al. Circulation. 2023;doi:10.1161/CIR.0000000000001191.
- Khan SS, et al. Circulation. 2023;doi:10.1161/CIRCULATIONAHA.123.067626.
- Ndumele CE, et al. Circulation. 2023;doi:10.1161/CIR.0000000000001186.
- SCORE2-Diabetes Working Group and the ESC Cardiovascular Risk Collaboration. Eur Heart J. 2023;doi:10.1093/eurheartj/ehad260.
- Wong ND, et al. Nat Rev Cardiol. 2023;doi:10.1038/s41569-023-00877-z.
- Zhao Y, et al. Diabetes Care. 2021;doi:10.2337/dc21-0431.
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Wong N. Importance of cardiovascular risk assessment and multiple risk factor control in diabetes. Presented at: World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease; Dec. 7-10, 2023; Los Angeles.
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