Identification and Predictors for Cardiovascular Disease Risk Equivalents Among Adults With Diabetes

Abstract

OBJECTIVE We examined diabetes as a cardiovascular disease (CVD) risk equivalent based on diabetes severity and other CVD risk factors. RESEARCH DESIGN AND METHODS We pooled four U.S. cohorts (Atherosclerosis Risk in Communities [ARIC], Jackson Heart Study [JHS], Multi-Ethnic Study of Atherosclerosis [MESA], and Framingham Heart Study Offspring Cohort [FHS-Offspring]) and classified subjects into groups by baseline diabetes/CVD status (positive or negative). CVD risks of the diabetes mellitus (DM)+/CVD− group versus DM−/CVD+ group were examined by diabetes severity and in subgroups of other CVD risk factors. We developed an algorithm to identify subjects with CVD risk equivalent diabetes by comparing the relative CVD risk of being DM+/CVD− versus DM−/CVD+. RESULTS The pooled cohort included 27,730 subjects (mean age 58.5 years, 44.6% male). CVD rates per 1,000 person-years were 16.5, 33.4, 43.2, and 71.4 among those DM−/CVD−, DM+/CVD−, DM−/CVD+, and DM+/CVD+, respectively. Compared with those DM−/CVD+, CVD risks were similar or higher for those with HbA1c ≥ 7%, diabetes duration ≥10 years, or diabetes medication use, while those with less severe diabetes had lower risks. Hazard ratios (95% CI) for DM+/CVD− vs. DM−/CVD+ were 0.96 (95% CI 0.86–1.07), 0.97 (0.88–1.07), 0.96 (0.82–1.13), 1.18 (0.98–1.41), 0.93 (0.85–1.02), and 1.00 (0.89–1.13) among women and those of White race, age <55 years, and with triglycerides ≥2.26 mmol/L, hs-CRP ≥2 mg/L, and estimated glomerular filtration rate <60 mL/min/1.73 m2, respectively. In the DM+/CVD− group, 19.1% had CVD risk equivalent diabetes with a lower risk score but a higher observed CVD risk. CONCLUSIONS Diabetes is a CVD risk equivalent in one-fifth of CVD-free adults living with diabetes. High HbA1c, long diabetes duration, and diabetes medication use were predictors of CVD risk equivalence. Diabetes is a CVD risk equivalent for women, white people, and those of younger age or with higher triglycerides or hs-CRP or reduced kidney function.