Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
  Users Online: 174 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  

 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 4  |  Page : 276-279  

A cross-sectional study to evaluate cardiovascular risk score in type 2 diabetes mellitus


1 Department of Pharmacology, Government Medical College, Rajindra Hospital, Patiala, Punjab, India
2 Department of Medicine, Rajindra Hospital, Patiala, Punjab, India

Date of Submission29-Jan-2020
Date of Decision25-Feb-2020
Date of Acceptance29-May-2020
Date of Web Publication04-Oct-2020

Correspondence Address:
Vijay Kumar Sehgal
Department of Pharmacology, Government Medical College, Patiala, Punjab
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijabmr.IJABMR_45_20

Rights and Permissions
   Abstract 


Background: Cardiovascular disease is the leading cause of mortality worldwide, including in low- and middle-income countries. Cardiovascular risk assessment is essential to prevent the mortality caused by diabetes. Aim: The current study was conducted to assess the prevalence of cardiovascular risk factors in type 2 diabetes and to compare the United Kingdom Prospective Diabetes Study (UKPDS) and World Health Organization (WHO)/International Society of Hypertension (ISH) chart in assessing cardiovascular risk score. Materials and Methods: Cardiac risk assessments were done in fifty patients attending the medicine outpatient department in an institutional hospital after ethical clearance and taking informed consent from patients. Two assessment tools were applied on the same patient. Results: Overall, 10% of people were obese (body mass index >30). Smoking was prevalent in 20% (10/50) of patients. Hypertension was observed in 60% (30/50) of patients. Raised total cholesterol (TC) was the most common lipid abnormality affecting 94% of patients. The WHO/ISH prediction charts identified 14% and 10% of patients with cardiovascular risk category <10 and 10–20, whereas the UKPDS engine predicted 24% and 38% in the same category. In high-risk categories 30–40 and >40, the WHO/ISH score predicted a higher proportion of patients (18% and 32%) than the UKPDS engine (8% and 4%, respectively). Kappa value was calculated to calculate the degree of agreement between two tools, and it was found to be 0.781 (P < 0.01). Conclusion: Raised TC and hypertension were the most prevalent risk factors. There was no significant discrepancy between two assessment tools in predicting cardiovascular risk score among type 2 diabetes mellitus patients in our study.

Keywords: Cardiovascular risk score, International Society of Hypertension, type 2 diabetes mellitus, United Kingdom Prospective Diabetes Study


How to cite this article:
Sehgal A, S Sibia R P, Kaur J, Bhajni E, Sehgal VK. A cross-sectional study to evaluate cardiovascular risk score in type 2 diabetes mellitus. Int J App Basic Med Res 2020;10:276-9

How to cite this URL:
Sehgal A, S Sibia R P, Kaur J, Bhajni E, Sehgal VK. A cross-sectional study to evaluate cardiovascular risk score in type 2 diabetes mellitus. Int J App Basic Med Res [serial online] 2020 [cited 2020 Oct 24];10:276-9. Available from: https://www.ijabmr.org/text.asp?2020/10/4/276/297260




   Introduction Top


Cardiovascular disease (CVD) is the leading cause of mortality worldwide, including in low- and middle-income countries.[1] India contributed one-fifth (18.6%) of the global CVD burden as measured by disability-adjusted life years in 2016.[2] It is well known that diabetes is associated with increased cardiovascular morbidity and mortality.[3] Primary preventive measures are effective in reducing cardiovascular events in type 2 diabetes mellitus (T2DM), especially lipid-lowering therapy with statin, lowering blood pressure with antihypertensives, and antiplatelet therapy with aspirin. These measures are indicated depending on cardiac risk of the patient.[4],[5],[6]

There are several cardiac assessment tools to assess the cardiac risk such as Framingham Risk Score, United Kingdom Prospective Diabetes Study (UKPDS) risk engine and World Health Organization/International Society of Hypertension (WHO/ISH) charts, QRISK, Reynolds, and InterHeat. Unlike other tools, the UKPDS risk engine is diabetes-specific and it incorporates glycemia, systolic blood pressure (SBP), and lipid levels as risk factors, in addition to age, sex, ethnic group, smoking status, and time since diagnosis of diabetes. The WHO/ISH chart was developed on the epidemiologic findings of the South Asian region and includes five parameters that can be measurable at low-resource and primary care setting and include sex, age, SBP, smoking status, and serum total cholesterol (TC). Using the WHO/ISH charts, an individual's risk of developing a vascular event during the next 10 years is predicted as a probability. However, the major modifiable CVD risk factors in diabetes such as low-density lipoprotein (LDL) cholesterol and diastolic blood pressure for which therapeutic interventions have shown proven benefits have not been included in the WHO/ISH charts in order to reduce the cost of its application in the resource-poor setting.[7]

This study was designed to estimate the prevalence of CVD risk factors in T2DM patients and to compare the CVD risk estimated between the UKPDS risk engine and the WHO/ISH chart.


   Materials and Methods Top


A cross-sectional observational study was conducted in T2DM patients (n = 50) attending the medicine outpatient department in our hospital after obtaining ethical approval. Written informed consent was obtained from all the study participants. Inclusion criteria were as follows: age >40 years, sex – both male and female, patients with fasting blood sugar >110 mg/dl and glycosylated hemoglobin (HB1Ac) >8%, and diabetes duration >1 year. Children, pregnant women, seriously and acutely ill patients, patients unwilling to give written informed consent, and patients with prior history of CVD such as myocardial infarction, stroke, and coronary artery disease were excluded.

In all study patients (n = 50), pro forma was filled to obtain demographic and medical information such as age, sex, rural/urban, history of smoking, height, weight, blood pressure, and diabetes duration. The UKPDS risk engine and WHO/ISH risk prediction charts (South-East Asian Region [SEAR] D) were used to assess the prevalence of CVD risk among patients with T2DM over 10 years. Each patient's 10-year CVD risk was classified by both risk assessment tools into one of the five risk levels: <10%, 10%–20%, 20%–30%, 30%–40%, and >40%.

All the data obtained were analyzed using SPSS software version 19 (by IBM, New York, USA). Baseline characteristics and prevalence of cardiovascular risk factors were calculated using descriptive statistics (means and frequencies). Assessment of cardiovascular risk tools was done using the Chi-square test [Figure 1] and [Figure 2].
Figure 1: Baseline characteristics according to gender

Click here to view
Figure 2: Prevalence of cardiovascular disease risk factors

Click here to view



   Results Top


There were fifty patients with T2DM. Out of which, 42% were males (n = 21) and the mean age of males was 60.33 (standard deviation = 8.7) and 58% were females (n = 29) and the mean age of females was 57.62 (standard deviation = 9.7). The mean body mass index (BMI) was 25.26 ± 3.65, hemoglobin was 10.90 ± 1.32 g, and HB1Ac was 8.34% ± 0.66% [Table 1].
Table 1: Baseline characteristics of study population

Click here to view


Prevalence of cardiovascular disease risk factors

Raised TC was the most common lipid abnormality affecting 94% (47/50) of patients. Overall, 10% (5/50) of people were obese (BMI >30), of which the prevalence of obesity in females was 80% in comparison to 20% in males. Smoking was prevalent in 20% (10/50) of patients. Hypertension was observed in 60% (30/50) of patients, whereas the prevalence of low HDL cholesterol and hypertriglyceridemia was 8% (4/50), respectively.

Cardiovascular disease risk categories by two assessment tools

The WHO/ISH prediction charts identified 14% and 10% of patients with cardiovascular risk category <10 and 10–20 which was lower when compared to 24% and 38% as predicted by the UKPDS engine, respectively, in both categories. A similar proportion of the sample (26% by the WHO/ISH and UKPDS) was categorized in 20–30 category. In high-risk categories 30–40 and >40, the WHO/ISH score predicted a higher proportion of patients (18% and 32%) than the UKPDS engine (8% and 4%, respectively).

A comparison of the WHO/ISH and UKPDS risk charts in their ability to categorize patients with T2DM into different risk categories. Both tools recognized 8% (4/50) and 6% (3/50) of the sample as having low cardiac risk <10 and 10–20 categories, respectively. The UKPDS engine recognized 6% in 10–20 and 20–30 categories, whereas the WHO/ISH tool recognized them in <10 category. Similarly, the WHO/ISH risk chart recognized 26% (13/50) of the sample in 20–30 category and the UKPDS recognized the same 4% (2/50) of the sample in <10 category, 16% (8/50) in 10–20 category, 4% (2/50) in 20–30 category, and 2% (1/50) in 30–40 category [Table 2].
Table 2: Comparison of cardiovascular risk scores by two assessment tools

Click here to view


Kappa value was calculated to calculate the degree of agreement between two tools, and it was found to be 0.781 (P < 0.01). These findings reveal no significant difference between two tools [Table 3].
Table 3: Measurement of kappa value to calculate the degree of agreement

Click here to view



   Discussion Top


This study evaluated the prevalence of cardiovascular risk factors and compared the two cardiovascular risk calculators – UKPDS (risk engine) and WHO/ISH. The UKPDS engine is used for diabetes worldwide and the WHO/ISH risk prediction chart for the South East region (SEAR D) specific for India is used. This is the first study in the northern region of India to compare the assessment tools.

A study in Sri Lanka compared these two assessment tools and found that there was a significant discrepancy between two tools. The WHO/ISH risk chart classified a higher proportion (78.4%) of patients into low cardiac risk category (<10%) than the UKPDS risk engine (52.3%). However, at high-risk threshold of ≥30%, both methods were comparable and identified a similar proportion of patients (1.9% vs. 2.1%).[8],[9],[10] This study revealed that the prevalence of raised cholesterol was the most common cardiovascular risk factor, followed by hypertension, obesity, and smoking. The WHO/ISH prediction chart identified a low proportion of patients in lower category risk patients, whereas the UKPDS predicted a higher proportion in the same category. In high-risk categories, the WHO/ISH predicted a higher proportion of patients than the UKPDS. These findings show that the WHO/ISH prediction chart identified a higher proportion as the risk increased and the UKPDS engine predicted a lower proportion as the risk increased. This trend might be due to the UKPDS engine's poor ability to recognize high-risk patients and hence labeling them as a low cardiac risk.

There was no significant statistical difference found between two assessment tools in predicting cardiovascular risk. One previous study had shown that the UKPDS risk chart recognized a higher percentage of patients of Indian origin as high risk than the other ethnic groups.[11]

The UKPDS engine had an advantage of predicting fatal cardiovascular risk, stroke risk, and fatal stroke risk and takes into account glycemia, age, ethnicity, duration of diabetes, and smoking status, and the WHO/ISH prediction chart used has been designed for SEAR and takes into account of TC.

There were a number of limitations with this study. The sample size was small. The study did not take into account LDL cholesterol or the use of statin therapy which could have helped further in assessing the validity of tool. Furthermore, this study was conducted in one institution of northern India. The multicentric study would have shown up results on ethnic basis too.

This study revealed that any of the tools can be used for assessing the cardiovascular risk score in diabetes patients in Indian population as there was no significant difference found between two tools. Both tools are cost-effective as they are available free online. The assessment of cardiovascular risk score by any of the tools can be used by clinicians to educate the patient about their cardiovascular risk and it will motivate the patient to adopt better lifestyle and it will help the physician too, to adjust the dose of drugs accordingly.


   Conclusion Top


Raised TC and hypertension were the most prevalent risk factors. Obesity and smoking were the least prevalent risk factors. There was no significant discrepancy between two assessment tools in predicting cardiovascular risk score among T2DM patients in our study. The WHO/ISH prediction chart identified a low proportion of patients in lower category risk patients, whereas the UKPDS predicted a low proportion of patients in high risk.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
GBD 2016 Causes of Death Collaborators. Global, regional and national age-sex specific mortality for 264 causes of death, 1980-2016: A systematic analysis for the global burden of disease study 2016. Lancet 2017;390:1151-210.  Back to cited text no. 1
    
2.
GBD 2016 DALYs and HALE Collaborators. Global, regional and national disability –adjusted life years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2016: A systematic analysis for the global burden of disease study 2016. Lancet 2017;390:1260-344.  Back to cited text no. 2
    
3.
Sarwar N, Gao P, Seshasai SR, Gobin R, Kaptoge S, Di Angelantonio E, et al.; Emerging Risk Factors Collaboration. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: A collaborative meta-analysis of 102 prospective studies. Lancet 2010;375:2215-22.  Back to cited text no. 3
    
4.
Shepherd J, Cobbe SM, Ford I, Isles CG, Lorimer AR, MacFarlane PW, et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. N Engl J Med 1995;333:1301-7.  Back to cited text no. 4
    
5.
Heart Protection Study Collaborative Group. MRC/BHF heart protection study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: A randomised placebo-controlled trial. Lancet 2002;360:7-22.  Back to cited text no. 5
    
6.
American Diabetes Association. Standards of medical care in diabetes – 2014. Diabetes Care 2014;37 Suppl 1:S14-80.  Back to cited text no. 6
    
7.
Stevens RJ, Kothari V, Adler AI, Stratton IM; United Kingdom Prospective Diabetes Study (UKPDS) Group. The UKPDS risk engine: A model for the risk of coronary heart disease in Type II diabetes (UKPDS 56). Clin Sci (Lond) 2001;101:671-9.  Back to cited text no. 7
    
8.
Selvarajah S, Kaur G, Haniff J, Cheong KC, Hiong TG, van der Graaf Y, et al. Comparison of the Framingham Risk Score, SCORE and WHO/ISH cardiovascular risk prediction models in an Asian population. Int J Cardiol 2014;176:211-8.  Back to cited text no. 8
    
9.
Modesti PA, Agostoni P, Agyemang C, Basu S, Benetos A, Cappuccio FP, et al. Cardiovascular risk assessment in low-resource settings: A consensus document of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk in Low Resource Settings. J Hypertens 2014;32:951-60.  Back to cited text no. 9
    
10.
Al-Lawati JA, Barakat MN, Al-Lawati NA, Al-Maskari MY, Elsayed MK, Mikhailidis DP, et al. Cardiovascular risk assessment in diabetes mellitus: Comparison of the general Framingham risk profile versus the World Health Organization/International Society of Hypertension risk prediction charts in Arabs – Clinical implications. Angiology 2013;64:336-42.  Back to cited text no. 10
    
11.
Bansal M, Kasliwal RR, Trehan N. Comparative accuracy of different risk scores in assessing cardiovascular risk in Indians: A study in patients with first myocardial infarction. Indian Heart J 2014;66:580-6.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed83    
    Printed4    
    Emailed0    
    PDF Downloaded20    
    Comments [Add]    

Recommend this journal