Assessing Framingham cardiovascular risk scores in subjects with diabetes and their correlation with diabetic retinopathy

Framingham risk scores for determination the 10-year risk of cardiovascular disease in participants with and without the metabolic syndrome: results of the Fasa Persian cohort study

BACKGROUND

Metabolic syndrome (MetS) is a cluster of risk factors and the Framingham risk score (FRS) is a useful metric for measuring the 10-year cardiovascular disease (CVD) risk of the population. The present study aimed to determine the 10-year risk of cardiovascular disease using the Framingham risk score in people with and without MetS in a large Iranian cohort study.

METHODS

This cross-sectional study was done using the Fasa cohort. Participants aged ≥ 35 years old were recruited to the study from 2015 to 2016. The FRS was calculated using age, sex, current smoking, diabetes, systolic blood pressure (SBP), total cholesterol, and high-density lipoprotein (HDL) cholesterol. MetS was defined as the presence of three or more of the MetS risk factors including triglyceride (TG) level ≥ 150 mg dl- 1, HDL level < 40 mg dl- 1 in men and < 50 mg dl- 1 in women, systolic/diastolic blood pressure ≥ 130/≥85 mmHg or using medicine for hypertension, fasting blood sugar (FBS) level ≥ 100 mg dl- 1 or using diabetes medication and abdominal obesity considered as waist circumference (WC) ≥ 88 cm for women and ≥ 102 cm for men. Multiple logistic regressions were applied to estimate the 10- year CVD risk among people with and without MetS.

RESULTS

Of 8949 participants, 1928 people (21.6%) had MetS. The mean age of the participants with and without Mets was 50.4 ± 9.2 years and 46.9 ± 9.1 years respectively. In total 15.3% of participants with MetS and 8.0% of participants without MetS were in the high-risk category of 10-year CVD risk. Among participants with MetS gender, TG, SBP, FBS and in people without MetS gender, TG, SBP, FBS, and HDL showed strong associations with the predicted 10-year CVD risk.

CONCLUSION

Male sex and increased SBP, TG, and FBS parameters were strongly associated with increased 10-year risk of CVD in people with and without MetS. In people without MetS, reduced HDL-cholestrol was strongly associated with increased 10-year risk of CVD. The recognition of participant's TG, blood pressure (BP), FBS and planning appropriate lifestyle interventions related to these characteristics is an important step towards prevention of CVD.

Subclinical Inflammation Is Associated With Reductions in Muscle Oxygenation, Exercise Capacity and Quality of Life in Adults With Type 2 Diabetes

OBJECTIVES

Exercise capacity is related to both morbidity and mortality in patients with type 2 diabetes (T2DM). The aim of this study was to investigate the relationship between subclinical inflammation level, exercise capacity, muscle oxygenation and quality of life in T2DM.

METHODS

This study includes 28 patients with T2DM (mean age, 51.5±5.0 years; male-to-female ratio, 6:22). Exercise capacity was evaluated using an incremental symptom-limited maximal exercise test on a bicycle ergometer. Muscle oxygenation was investigated using a wearable lactate-measuring device. Diabetes-specific quality of life was assessed using the Diabetes Quality of Life Questionnaire (DQOL). Subclinical inflammation was assessed using C-reactive protein (CRP) levels.

RESULTS

CRP level was negatively correlated with peak workload during the test (r=-0.588, p=0.002), muscle oxygenation (r=-0.465, p=0.019) and the psychological impact of treatment subscale of the DQOL (r=-0.540, p=0.017), and positively correlated with body mass index (r=0.519, p=0.008), waist circumference (r=0.426, p=0.038) and fat percentage (r=0.573, p=0.004). There was no correlation between CRP and fasting blood glucose or glycated hemoglobin level (p>0.05). Peak workload was inversely related to fat percentage (r=-0.467, p=0.016) and the DQOL worry about the future impact of diabetes subscale (r=-0.501, p=0.021).

CONCLUSIONS

In our study, subclinical inflammation negatively affected muscle oxygenation, exercise capacity and quality of life independently of glycemic indicators. Our findings suggest that the degree of glycemic control is insufficient to explain lower exercise capacity. Further studies are needed to investigate subclinical inflammation-reducing interventions in T2DM.

Gender difference in the association between Framingham Risk Score with cardio-metabolic risk factors and psychological distress in patients with metabolic syndrome

BACKGROUND

In the current study we aimed to evaluate the gender-specific associations between metabolic and psychological risk factors of cardiovascular disease (CVD) and Framingham Risk Score (FRS) in patients with metabolic syndrome.

METHODS

In a cross-sectional study of 256 patients with metabolic syndrome (157 men, 99 women), the cardiovascular disease risk was evaluated using the FRS scoring system by a pre-defined computerized algorithm. Psychological distress was also assessed by general health questionnaire (GHQ)-12. Evaluation of the biochemical parameters including fasting serum glucose (FSG), lipid profile, liver enzymes and adiponectin concentrations were also performed using the enzymatic methods.

RESULTS

The prevalence of low, intermediate and high risk of CVD in men was significantly higher than women (P < 0.05). Both genders in high risk of CVD had significantly higher age, systolic blood pressure (SBP) and FSG concentrations compared with male and females in intermediate and low risk of CVD (P < 0.05). In multiple logistic regression, being single was in the highest relationship with high psychological distress values compared with married or divorced/separated marital status. Moreover, high SBP and low high density lipoprotein (HDL) concentrations were also potent determinants of high psychological distress (P < 0.05).

CONCLUSIONS

In the current study, the prevalence of CVD risk factors were higher in men compared with women. Moreover, higher age, SBP and FSG were potent determinants of FRS in both genders. Marital status and serum HDL were in relation with psychological distress among patients with metabolic syndrome.

Prognostic tools for cardiovascular disease in patients with type 2 diabetes: A systematic review and meta-analysis of C-statistics

BACKGROUND

Diabetes is associated with an increased risk for cardiovascular diseases (CVD). Risk prediction models are tools widely used to identify individuals at particularly high-risk of adverse events. Many CVD risk prediction models have been developed but their accuracy and consistency vary.

OBJECTIVE

This study reviews the literature on available CVD risk prediction models specifically developed or validated in patients with diabetes and performs a meta-analysis of C-statistics to assess and compare their predictive performance.

METHODS

The online databases and manual reference checks of all identified relevant publications were searched.

RESULTS

Fifteen CVD prediction models developed for patients with diabetes and 11 models developed in a general population but later validated in diabetes patients were identified. Meta-analysis of C-statistics showed an overall pooled C-statistic of 0.67 and 0.64 for validated models developed in diabetes patients and in general populations respectively. This small difference in the C-statistic suggests that CVD risk prediction for diabetes patients depends little on the population the model was developed in (p = 0.068).

CONCLUSIONS

The discriminative ability of diabetes-specific CVD prediction models were modest. Improvements in the predictive ability of these models are required to understand both short and long-term risk before implementation into clinical practice.

Incidence and progression of diabetic retinopathy in Sub-Saharan Africa: A five year cohort study

Aims

To describe the incidence and progression of retinopathy in people with diabetes in Southern Malawi over 5 years. To document visual loss in a setting where laser treatment is not available.

Methods

Subjects from a cohort sampled from a hospital-based, primary-care diabetes clinic in 2007 were traced in 2012. Laser treatment was not available. Modified Wisconsin grading of retinopathy was performed using slit lamp biomicroscopy by a single ophthalmologist in 2007 and using four-field mydriatic fundus photographs at an accredited reading centre in 2012. Visual acuity was measured by Snellen chart in 2007 and by ‘Early Treatment of Diabetic Retinopathy Study’ chart in 2012. HbA1c, blood pressure, HIV status, urine albumin–creatinine ratio, haemoglobin and lipids were measured.

Results

Of 281 subjects recruited in 2007, 135 (48%) were traced and assessed, 15 were confirmed dead. At follow-up (median 5.3 years) ≥2 step retinopathy progression was observed in 48 subjects (36.4%; 95% CI 28.2–44.6). Incidence of sight threatening diabetic retinopathy for those with level 10 (no retinopathy) and level 20 (background) retinopathy at baseline, was 19.4% (11.3–27.4) and 81.3% (62.1–100), respectively. In multivariate analysis 2 step progression was associated with HbA1c (OR 1.2495%CI 1.04–1.48), and haemoglobin level (0.77, 0.62–0.98). 25 subjects (18.8%) lost ≥5 letters, 7 (5.3%) lost ≥15 letters.

Conclusions

Progression to sight threatening diabetic retinopathy from no retinopathy and background retinopathy was approximately 5 and 3 times that reported in recent European studies, respectively. Incidence of visual loss was high in a location where treatment was not available.

Prevalence of diabetic retinopathy in India: The All India Ophthalmological Society Diabetic Retinopathy Eye Screening Study 2014

Aim:

The aim of this study is to ascertain the prevalence of diabetic retinopathy (DR) in diabetic patients across the nation and attempt to establish history-based risk factors.

Materials and Methods:

A cross-sectional study of diabetic patients was conducted as an initiative of the All India Ophthalmological Society from 14^th November to 21^st November 2014. Known diabetics were evaluated voluntarily by members of the society at 194 centers using a structured protocol provided by the society for examination. The results were evaluated to ascertain the prevalence of DR in the population studied and to establish relation with gender, age, and history-based risk factors such as duration of diabetes, insulin use, and other end-organ disease using the Chi-square test.

Results:

A total of 6218 known diabetics were screened. Totally, 5130 data entry forms were considered suitable for further evaluation. About 61.2% were males, 88.6% were between 40 and 80 years of age, almost two-thirds of the patients were from the west and south zones, and over half had diabetes more than 5 years. The data set was predominantly urban 84.7% and 46.1% had no family history. DR prevalence in the entire data set was 21.7%. Prevalence was more in males (P = 0.007), diabetics more than 5 years (P = 0.001), those above 40 years (P = 0.01), insulin users (P = 0.001), and history of vascular accidents (P = 0.0014). Significantly 22.18% of patients detected with DR had a vision of 6/18 or better in the worse eye.

Conclusion:

The study reiterated the findings of earlier regional studies on a pan Indian scale and put data in perspective.

First Prospective Cohort Study of Diabetic Retinopathy from Sub-Saharan Africa: High Incidence and Progression of Retinopathy and Relationship to Human Immunodeficiency Virus Infection

PURPOSE

To describe the prevalence, incidence, and progression of retinopathy and to report associations with demographic, clinical, and biochemical variables in people with diabetes in Southern Malawi.

DESIGN

Prospective cohort study.

PARTICIPANTS

Subjects were systematically sampled from 2 primary care diabetes clinics.

METHODS

We performed the first prospective cohort study of diabetic retinopathy from Sub-Saharan Africa over 24 months. Visual acuity, glycemic control, blood pressure, human immunodeficiency virus (HIV) status, urine albumin-to-creatinine ratio, hemoglobin, and lipids were assessed. Retinopathy was graded at an accredited reading center using modified Wisconsin grading of 4-field mydriatic photographs.

MAIN OUTCOME MEASURES

Incidence of sight-threatening retinopathy and progression of retinopathy by 2 steps on the Liverpool Diabetic Eye Study Scale.

RESULTS

A total of 357 subjects were recruited to the 24-month cohort study. At baseline, 13.4% of subjects were HIV positive and 15.1% were anemic. The 2-year incidence of sight-threatening diabetic retinopathy (STDR) for subjects with level 10 (no retinopathy), level 20 (background), and level 30 (preproliferative) retinopathy at baseline was 2.7% (95% confidence interval [CI], 0.1-5.3), 27.3% (95% CI, 16.4-38.2), and 25.0% (95% CI, 0-67.4), respectively. In a multivariate logistic analysis, 2-step progression of diabetic retinopathy was associated with glycosylated hemoglobin (odds ratio [OR], 1.27; 95% CI, 1.12-1.45), baseline grade of retinopathy (OR, 1.39; 95% CI, 1.02-1.91), and HIV infection (OR, 0.16; 95% CI, 0.03-0.78). At 2 years, 17 subjects (5.8%) lost ≥15 letters.

CONCLUSIONS

Incidence of STDR was approximately 3 times that reported in recent European studies. The negative association of HIV infection with retinopathy progression is a new finding.

Assessment of Cardiovascular Risk in Adults With Type 2 Diabetes and Metabolic Syndrome

Purpose

The purpose of this study was to assess risk of cardiovascular disease (CVD) by comparing the Framingham and United Kingdom Prospective Diabetes Study (UKPDS) risk equations in Korean adults with type 2 diabetes (T2DM) and metabolic syndrome.

Methods

The study was a cross-sectional survey enrolling a convenience sample of 110 Korean adults with T2DM and metabolic syndrome. The 10-year CVD risk scores were calculated using the Framingham risk equation and UKPDS risk engines.

Results

Overall participants had a moderate prevalence (average, 64.3%) of metabolic syndrome factors, with the most prevalent being abdominal obesity (86.4%) and elevated blood pressure (78.2%). A lower percentage of women were current smokers and consumed alcohol than men, whereas a higher percentage of men had their weight and stress controlled than women. The mean scores of 10-year CVD risk using the Framingham and UKPDS equations were 14.55% and 15.99%, respectively. However, there were no significant differences between results of the 2 equations. Regarding level of CVD risk, the percentage of high risk (>20%) was about 24% using both equations. Also, the area under the receiver operating characteristic curves using Framingham and UKPDS equations was similar: 0.707 and 0.696, respectively, which indicated moderate accuracy.

Conclusions

About one-fourth of adults with T2DM and metabolic syndrome had high level of CVD risk (>20%). In practice, people with diabetes and metabolic syndrome could be managed earlier and more intensively based on their risk estimated by the Framingham or UKPDS equations.