Cardiovascular risk assessment in type 2 diabetes mellitus: comparison of the World Health Organization/International Society of Hypertension risk prediction charts versus UK Prospective Diabetes Study risk engine

Cardiovascular Risk Profiling Using the Globorisk Calculator among Noncommunicable Disease Patients Attending Primary Health Centers of a Tertiary Care Teaching Hospital in South India: A Cross-Sectional Analytical Study

Background

Cardiovascular diseases (CVDs) account for over three-quarters of all deaths taking place in developing nations.

Objective

The present study aims to stratify noncommunicable disease (NCD) patients using the Globorisk chart for predicting their 10-year risk of a major (fatal or nonfatal) CVD event and to estimate the level of agreement between this country-specific chart and the existing World Health Organization (WHO)/International Society of Hypertension (ISH) risk strata.

Methods

A record-based cross-sectional analytical study was conducted in 2018 among adults attending the NCD clinic of one rural and one urban primary health center in Puducherry. Laboratory and office risk calculators of the Globorisk chart were used to calculate the risk.

Results

The median age (interquartile range (IQR)) of the 760 study participants was 58 (50-65) years. When calculated using the Globorisk prediction chart, 22.1% (n = 168) of the participants had a <10% risk for any CVD event in the next 10 years, whereas the same risk was found in 71.1% (n = 540) by using the WHO/ISH risk chart. There was no agreement found between the two risk charts (k = 0.0174; P-value = 0.26).

Conclusion

The Globorisk chart was found to identify more patients as belonging to the higher risk category as compared to WHO/ISH charts.

Experiences of successful physical activity maintenance among adults with type 2 diabetes: a theory-based qualitative study

OBJECTIVE

Approximately 70% of adults with type 2 diabetes (T2D) fail to achieve the 150 minutes of weekly physical activity (PA) recommended for self-management. Interventions to promote PA adoption in T2D rarely achieve stable maintenance. Analysis of lived experiences of adults with T2D who have successfully transitioned to long-term PA maintenance can build understanding of factors influencing long-term maintenance.

DESIGN

Semi-structured interviews were conducted among 18 adults with T2D who had transitioned to a lifestyle incorporating maintenance of recommended PA. Interview topics were informed by the three phases of the 'Multi-Process Action Control' (M-PAC) Framework, and explored attitudes, beliefs and experiences relating to PA decision, adoption and the transition to stable maintenance. Transcripts were thematically analysed.

FINDINGS

Seven themes emerged. Results variously showed that negative affect engendered by T2D diagnosis and inspiration from peers influenced intention formation, and that setting easy, fun goals, and experiencing biopsychosocial gains were important to behaviour adoption. PA maintenance was regulated by habit, expectations of positive affect, and a new sense of identity.

CONCLUSION

Phase-based frameworks can help understand how regulation of behaviour evolves over time. PA promotion strategies for inactive adults with T2D should be phase-tailored, to help people transition from intentions to maintenance.

Performance of WHO updated cardiovascular disease risk prediction charts in a low-resource setting - Findings from a community-based survey in Puducherry, India

BACKGROUND AND AIM

The World Health Organization has revised the cardiovascular disease (CVD) risk prediction charts in 2019 for each of the 21 Global Burden of Disease regions. These charts (non-lab and lab versions) estimate the total CVD risk in an individual, of which the non-lab is for low-resource settings. We aimed to estimate the burden of ten-year risk of fatal or non-fatal CVD event in the district of Puducherry in India using 'non-lab' and 'lab' versions of WHO CVD risk prediction charts, and to evaluate the agreement between them.

METHODS AND RESULTS

We included 710 individuals aged 40-69 years who participated in a district wide non-communicable diseases survey conducted in Puducherry, India, during 2019-20. Both charts use information on age, gender, systolic blood pressure and smoking status. Additionally, lab-chart requires individual's status on diabetes mellitus and total cholesterol while non-lab requires body mass index. Population in different CVD risk levels was presented using proportions (95% confidence intervals). Agreement between lab and non-lab charts was evaluated using Cohen's Kappa (k). The lab and non-lab charts estimated 3% (95% CI: 1.7-4.2) and none of the population respectively, to have high risk (≥20%) for fatal or non-fatal CVD event over the next ten years. Both the charts showed 89.4% (95% CI:87.2%-91.7%) concordance in CVD risk prediction indicating a good level of agreement (k = 0.653).

CONCLUSION

WHO updated CVD risk prediction charts are feasible to apply when data is available and there is good agreement between non-lab and lab based charts.

Treatment and control of modifiable cardiovascular risk factors among patients with diabetes mellitus and hypertension in Inner Mongolia: A cross-sectional study

The authors assessed treatment and control of blood glucose, blood pressure (BP), and blood lipids among patients from Inner Mongolia with diabetes mellitus (DM) and hypertension (HTN) and identified the modifiable factors associated with treatment and achievement of blood glucose, BP, and blood lipid targets. The authors used a multistage stratified cluster sampling method according to geographical location and level of economic development in Inner Mongolia. Among patients with DM and HTN, the crude rates of fasting plasma glucose (FPG) treatment and control was 30.76% and 4.73%, respectively. Crude rates of BP treatment and control were 50.81% and 8.70%, respectively. The authors found that treatment rates of HTN and DM and control rates of BP and FPG showed a gradually increasing trend with increased age. Among patients with DM and HTN, the likelihood of treatment for HTN and DM was significantly increased among participants who were older, non‐Mongolian, male, obese, smokers, and those with previous cardiovascular disease. The authors found that control of BP, FPG, and low‐density lipoprotein cholesterol was far from optimal among study participants. Medical and health departments in Inner Mongolia should take appropriate measures to reduce the burden of DM and HTN in the population, such as by promoting and improving the quality of HTN and DM treatment to achieve control goals and reduce the risk of cardiovascular disease.

Cardiovascular risk assessment among type-2 diabetic subjects in selected areas of Bangladesh: concordance among without cholesterol-based WHO/ISH, Globorisk, and Framingham risk prediction tools

INTRODUCTION

Cardiovascular disease (CVD) risk is higher among the subjects with type-2 diabetes mellitus (T2DM) in low- and middle-income countries, like Bangladesh. However, there is no relevant available online published data for this country. We aimed at assessing the 10-year CVD risk among T2DM subjects in selected areas of Bangladesh using the without cholesterol-based joint World Health Organization/International Society of Hypertension (WHO/ISH), Globorisk, and Framingham Risk Score (FRS) risk prediction tools, and also evaluating the concordance among these tools.

METHODS AND MATERIALS

In this paper, we extracted a total of 327 subjects (40-60 years aged) from an observational study with 356 subjects, excluding those with diagnosed CVDs. The subjects were selected conveniently from purposively selected respective diabetic hospitals of Pirojpur and Dinajpur districts. We used the required respective variables of WHO/ISH, Globorisk, and FRS tools to predict CVD risks. The risks were categorized as low (<10%), moderate (10-<20%), high (20-<30%) and very high (≥30%).

RESULTS

Subjects at moderate CVD risk were much higher identified by Globorisk (37.0%) and FRS (38.8%) compared to WHO/ISH (15.3%), and the same scenarios have also been observed for high (13.5%, 19.3% and 2.4%, respectively) and very high (5.5%, 17.4% and 1.8%, respectively) risks. There was fair level of concordance between WHO/ISH and Globorisk (PABAK-OS k = 0.37; 95% CI 0.33-0.42; P < 0.001), and Globorisk and FRS (PABAK-OS k = 0.34; 95% CI 0.30-0.39; P < 0.001). And, between WHO/ISH and FRS, it was none to slight level (PABAK-OS k = 0.09, 95% CI 0.04-0.14; P = 0.001).

CONCLUSIONS

A significant proportion of the selected study subjects is at moderate to very high risk of developing CVDs predicted especially by Globorisk and FRS compared to WHO/ISH, indicating low concordance. With and without cholesterol-based studies can answer the problem more clearly.

Cardiovascular Risk Prediction, Glycemic Control, and Determinants in Diabetic and Hypertensive Patients in Massawa Hospital, Eritrea: Cross-Sectional Study on 600 Subjects

BACKGROUND

Hypertension and diabetes are key determinants of cardiovascular risks. The objective of this study was to calculate 10-year incidence of cardiovascular risk, determine cardiovascular risk factors, and evaluate how diabetes and hypertension are controlled in patients in Massawa Hospital, Eritrea.

METHODS

This was a hospital-based cross-sectional study using census sampling. A checklist and interview were used as data-collection tool from October 10 to November 20, 2020. Written consent was obtained from each study participant before starting the study. Descriptive statistics were wasused, and results are presented in percentages in tables, p<0.05 was considered significant.

RESULTS

A total of 600 patients were enrolled in the study, dominated by the Tigrigna (58.7%) and Tigre (26.7%) ethnic groups. About half the patients (58.8%) had a body-mass index of 18-25 kg/m², with abdominal circumference of <95 cm (74%). Most (93.5%) patients had <10% risk of cardiovascular complications in the coming 10 years. Age showed significant association with hypertension, diabetes mellitus, cardiovascular risk, and poor glycemic and blood-pressure control (p<0.001). Body-mass index, abdominal obesity, and history of stroke were associated with hypertension and diabetes mellitus (p<0.001). Moreover, smoking, hypertension, and monthly income were associated with higher cardiovascular risk (p<0.001). In addition, hypertension and abdominal obesity were associated with glycemic control (p<0.001), and blood-pressure control was significantly associated with diabetes and hypertension (p<0.001).

CONCLUSION

Age and hypertension were associated with diabetes, cardiovascular risk and poor glycemic control, and smoking, abdominal obesity, and monthly income also significant associations with higher cardiovascular risk and glycemic control. Cessation and adjustment of modifiable factors, such as smoking, hypertension, and regular exercise are highly recommended.

Assessment of cardiovascular disease risk in Northern China: a cross-sectional study

Cardiovascular disease (CVD) is a life-threatening chronic illness. CVD risk may be influenced by environment and lifestyle. People in northern China usually consume high-fat, high-salt diets and alcohol and live in a cold climate over long periods. However, there are limited studies on CVD risk among people in northern China. In the present study, we sought to estimate the CVD risk profile among residents of northern China. Using the Programme of Screening and Intervention Subjects with High Risk Cardiovascular Diseases, we collected data from residents in six cities from September 2015 to June 2017. In total, 56,716 participants aged 40 years and above were finally included in the CVD risk assessment. To assess the 10-year risk of CVD among participants, we used World Health Organisation/International Society of Hypertension risk prediction charts. Among the study participants, 22.7% had a high 10-year risk of CVD. We identified differences in the 10-year CVD risk according to sex, socioeconomic status, and marital status. We conclude that individuals with high socioeconomic status should be encouraged to change their lifestyle habits, and greater medical resources should be invested for individuals residing in rural areas and those with low education levels.

Cellular Fibronectin Containing Extra Domain A Causes Insulin Resistance via Toll-like Receptor 4

We determined the role of cellular fibronectin (CFN) containing the alternatively spliced extra domain A (FN-EDA) in causing insulin resistance (IR) through toll-like receptor 4 (TLR4). Circulating FN-EDA level was evaluated in mouse and rat IR models. Specific anti-FN-EDA antibody and TLR4 inhibitor were used to study its role in IR in mice. CFN protein was injected to evaluate TLR4 dependent effect of FN-EDA in IR. Furthermore, FN-EDA was estimated in blood plasma and correlated with demographic and clinical characteristics in healthy human participants (n = 38). High-fat diet feeding significantly increased circulating FN-EDA in both mouse (P = 0.03) and rat (P = 0.02) IR models. Antibody against FN-EDA protected mice from IR by increasing glucose disposal rate following glucose (P = 0.02) and insulin (P = 0.01) tolerance tests. CFN protein injection caused IR, however, TLR4 inhibitor protected the mice from CFN induced IR. Multivariate regression analysis predicted an independent positive correlation between circulating FN-EDA and fasting plasma glucose (P = 0.003) in healthy human participants. In conclusion, FN-EDA may cause IR through TLR4 by decreasing glucose disposal rate following glucose and insulin load. Targeting FN-EDA thus can be considered as a possible therapeutic strategy to delay prediabetes progression to diabetes.

10-year risk for cardiovascular diseases using WHO prediction chart: findings from the civil servants in South-western Nigeria

Background

Globally, cardiovascular diseases (CVDs) have continued to ravage the human existence through the premature deaths of its workforce. Despite this burden, many studies in Nigeria have focused on determining the prevalence of risk factors which alone are insufficient to assess the risk of future cardiovascular events. Therefore, we determined the pattern and predictors of 10-year risk for CVDs in South-western Nigeria.

Methods

We conducted a cross-sectional study among workers at the local government areas (LGAs) of Oyo State. Using a multi-stage sampling technique, we recruited 260 respondents from the LGA secretariats. A pre-tested, interviewer-administered questionnaire was administered to obtain information on the socio-demographics and behavioural attributes. Lipid analysis, anthropometric, blood pressure, fasting blood glucose measurements were done using standard protocols. The respondents’ CVD risk was assessed using WHO prediction chart. Data were analyzed using IBM SPSS version 25; bivariate analysis was done using Chi-square and binary logistic regression was used to identify the predictors of 10-year risk for CVDs at 5% level of significance.

Results

The mean age of respondents was 46.0 + 6.7 years. The proportion of respondents with good knowledge of risk factors was 57.7%. The prevalence of CVD risk factors were as follows: systolic hypertension (29.6%), visceral obesity (35.8%), diabetes mellitus (18.8%), smoking (5.8%), elevated total cholesterol (55.4%) and physical inactivity (84.6%). The proportion of respondents with low, moderate and high risk of developing CVDs within 10 years was 76.9, 8.5 and 14.6% respectively. Respondents with age ≥ 40 years (aOR = 2.6, 95% CI = 1.3–8.5), management cadre (aOR = 3.8, 95% CI = 1.6–9.6), obesity (aOR = 4.8, 95% CI = 1.2–120), abnormal waist circumference (aOR = 2.8, 95% CI = 1.3–5.2) and physical inactivity (aOR = 2.4, 95% CI = 1.2–4.7) were associated with the higher likelihood of developing CVDs.

Conclusion

About one-sixth of the respondents had high risk of developing CVDs within the next 10 years and it is likely that it will reduce the productivity of the State. Lifestyle modification and early detection of risk factors through regular screening programmes for those with high CVD risk is therefore recommended.

Prevalence of low HDL cholesterol and its associations among Sri Lankan patients with diabetes mellitus on statin therapy

AIMS

We aimed to study the prevalence and associations of suboptimal high density lipoproteins level, a characteristic feature in diabetic dyslipidemia among patients under statin therapy.

MATERIALS AND METHODS

From a database of 2416 patients, data on age, gender, duration of diabetes, body mass index (BMI) and waist circumference (WC), low density lipoproteins (LDL), triglyceride, high density lipoproteins (HDL) were obtained. Prevalence of suboptimal HDL (<40mg/dL in males and <50mg/dL in females) and its association with gender, age, duration of diabetes, BMI and WC were studied.

RESULTS

The mean (SD) age of the sample (n=2416) was 53 (10) years and 64.2% of them (n=1550) were males. Prevalence of suboptimal HDL was 17.6%. Regression analysis revealed female gender, (OR 7.73, 95% CI 5.99-9.97) younger age (OR 0.98, 95% CI 0.97-0.99), higher BMI (OR1.05. 95% CI 1.00-1.2) and LDL level over 100mg/dL (OR 1.004, 95% CI 1.00-1.007) had significant associations with suboptimal HDL.

CONCLUSIONS

Every sixth diabetic patient on statins has suboptimal HDL level. Females, younger and obese diabetic individuals should be more focused on achieving optimal HDL cholesterol levels.

Association of Risk Estimates of Three Different Cardiovascular Risk Assessment Tools with Carotid Intima Media Thickness in Patients with Type 2 Diabetes

INTRODUCTION

Risk assessment tools used to calculate the Cardiovascular Disease (CVD) risk such as the Framingham Risk Score (FRS), United Kingdom Prospective Diabetes study (UKPDS) risk engine and the World Health Organization (WHO) risk score have not been tested on their ability to detect subclinical atherosclerosis in most developing countries.

AIM

To study the association between the calculated CVD risk scores using each of these tools and Carotid Intima Medial Thickness (CIMT), a surrogate marker of atherosclerosis, in a group of patients with Type 2 diabetes (T2DM) in Sri Lanka.

MATERIALS AND METHODS

We calculated CVD risk scores of 68 randomly selected patients with T2DM with no history or symptoms of CVD and measured their CIMT using B-mode ultrasonography (USS). Carotid USS was considered positive when the maximum carotid IMT was 0.9mm or when arteriosclerotic plaques were detected. The 10-year CVD risk was calculated using the FRS, the UKPDS risk engine and the WHO risk score. Pearson correlation was used to study the association between CVD risk scores with CIMT.

RESULTS

Of the 68 patients studied, 50% were males and their mean age (SD) was 56.9 (±9.6) years. The mean age at onset and duration of diabetes were 44.3(±9.1) and 12.2(±7.6) years respectively. Of the scoring methods, UKPDS tool had weak, but significantly positive (r = 0.26, p < 0.05) and FRS had positive but not significant association (r= 0. 21) with CIMT. There was a negative association between CIMT and WHO risk score (r= - 0.07).

CONCLUSION

Of the three CVD risk assessment tools, both UKPDS risk engine and FRS have almost equal ability (former being marginally superior) in predicting underlying atherosclerotic vascular disease in patients with T2DM. Negative association of the WHO risk score with CIMT argues against its utility for CVD screening. These findings highlight the need for developing more sensitive and reliable CVD risk assessment tools for developing countries.