Aims: For patients with diabetes, the European guidelines updated the cardiovascular disease (CVD) risk prediction recommendations using diabetes-specific models with age-specific cut-offs, whereas American guidelines still advise models derived from the general population. We aimed to compare the performance of four cardiovascular risk models in diabetes populations.
Methods and results: Patients with diabetes from the CHERRY study, an electronic health records-based cohort study in China, were identified. Five-year CVD risk was calculated using original and recalibrated diabetes-specific models [Action in Diabetes and Vascular disease: PreterAx and diamicroN-MR Controlled Evaluation (ADVANCE) and the Hong Kong cardiovascular risk model (HK)] and general population-based models [Pooled Cohort Equations (PCE) and Prediction for Atherosclerotic cardiovascular disease Risk in China (China-PAR)]. During a median 5.8-year follow-up, 46 558 patients had 2605 CVD events. C-statistics were 0.711 [95% confidence interval: 0.693-0.729] for ADVANCE and 0.701 (0.683-0.719) for HK in men, and 0.742 (0.725-0.759) and 0.732 (0.718-0.747) in women. C-statistics were worse in two general population-based models. Recalibrated ADVANCE underestimated risk by 1.2% and 16.8% in men and women, whereas PCE underestimated risk by 41.9% and 24.2% in men and women. With the age-specific cut-offs, the overlap of the high-risk patients selected by every model pair ranged from only 22.6% to 51.2%. When utilizing the fixed cut-off at 5%, the recalibrated ADVANCE selected similar high-risk patients in men (7400) as compared to the age-specific cut-offs (7102), whereas age-specific cut-offs exhibited a reduction in the selection of high-risk patients in women (2646 under age-specific cut-offs vs. 3647 under fixed cut-off).
Conclusion: Diabetes-specific CVD risk prediction models showed better discrimination for patients with diabetes. High-risk patients selected by different models varied significantly. Age-specific cut-offs selected fewer patients at high CVD risk especially in women.
Keywords: Cardiovascular disease; Chinese; Cohort analysis; Diabetes; Risk prediction model.
This large electronic health records-based real-world study indicated that the diabetes-specific cardiovascular risk models had better discriminative abilities than the models derived from the general population in Chinese patients with Type 2 diabetes.Current guidelines-recommended models, i.e. ADVANCE, PCE, and China-PAR, selected significantly different high-risk groups with various observed cardiovascular risks, indicating the potential considerable misclassification of risk stratification in clinical decision-making for preventive interventions.Compared with the fixed cut-off, the influence of the age-specific cut-offs for high risk of cardiovascular disease was different in men and women: age-specific cut-offs selected ∼27% fewer high-risk patients in women but similar in men.
© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.