Prediction of Coronary Heart Disease in Middle-Aged Adults With Diabetes

Abstract

OBJECTIVE -To determine the 10-year probability of coronary heart disease (CHD) in diabetic adults and how well basic and novel risk factors predict CHD risk.RESEARCH DESIGN AND METHODS -We measured risk factors in 14,054 participants (1,500 with diabetes) initially free of CHD in the Atherosclerosis Risk in Communities study from 1987 to 1989 and followed them prospectively for CHD incidence through 1998. We used proportional hazards regression models and receiver operating characteristic (ROC) curves for CHD risk prediction.RESULTS -Based on our model using basic risk factors (age, race, total and HDL cholesterol, systolic blood pressure, antihypertensives, and smoking status), ϳ61% of diabetic women and 86% of diabetic men had a predicted 10-year CHD probability Ն10%. This CHD risk-prediction model had an area under the ROC curve of 0.72 in diabetic women and 0.67 in diabetic men. Novel risk factors or subclinical disease markers individually added only modest predictivity, but the addition of multiple markers (BMI, waist-to-hip ratio, Keys dietary score, serum albumin and creatinine, factor VIII, white blood cell count, left ventricular hypertrophy determined by electrocardiogram, and carotid intima-media thickness) increased the area under the curve by ϳ10%.CONCLUSIONS -Although all diabetic adults are at high risk for CHD, their variation in CHD risk can be predicted moderately well by basic risk factors. No single novel risk marker greatly enhanced absolute CHD risk assessment, but a battery of novel markers did. Our model can provide estimates of CHD risk for the primary prevention of this disease in people with type 2 diabetes. Diabetes Care 26:2777-2784, 2003U sing multivariable risk assessment to define the likelihood of a coronary heart disease (CHD) event has become a cornerstone of preventive cardiology. The Framingham Study provided the most widely used CHD risk equation (1), which generalizes fairly well to other healthy populations (2). The Framingham model includes a variable for diabetes status (yes/no), but the U.K. Prospective Diabetes Study recently provided a multivariable CHD risk equation specifically for people with diabetes (3).People with diabetes are at particularly high risk of CHD, so much so that the National Cholesterol Education Program (NCEP) now recommends that diabetic patients do not need specific CHD risk assessment, but instead that they be managed as if they had CHD (4). Likewise, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) recommends that hypertension be aggressively managed in diabetic patients (5). However, absolute CHD risk varies within the diabetic population and further risk stratification might help in making clinical decisions about aggressiveness of preventive management. The recent American Heart Association's Prevention Conference VI reviewed various means beyond basic risk factor assessment to accomplish CHD risk assessment in diabetic patients (6). However, epidemiological data on the value of...

Coronary Heart Disease Risk Equivalence in Diabetes Depends on Concomitant Risk Factors

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Exercise Capacity and Body Mass as Predictors of Mortality Among Male Veterans With Type 2 Diabetes

“…Among patients with type 2 diabetes, CVD accounts for Ͼ75% of total mortality (15), and hypertension, dyslipidemia, and smoking are each independent predictors of CVD mortality (16,17). However, the relation of obesity to CVD mortality remains controversial.…”

353 Prevalence of Chronic Atrial Fibrillation in Dialysis Patients

“…Among individuals without HTN as their primary cause of ESRD, AF was less common in individuals with HTN as a comorbidity than in those without. While HTN is a risk factor for AF in the general population [19][20][21][22][23][24] , in ESRD, studies of prevalent dialysis patients may be characterized by a distinct physiology, namely the controversially-termed phenomenon of "reverse epidemiology" 25,26 . Evidence from the DOPPS database appears to support our results: while a formal diagnosis of hypertension was not associated with AF, low pre-dialysis systolic blood pressure was 8 , lending plausibility to the hypothesis that when dialysis patients manifest AF, many of them are experiencing decreased cardiac output and concomitant hypotension.…”