CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 9/10, October/November 2013
AFRICA
379
Interestingly, the agreement between predictions by the
ADVANCE models and the observed CVD events was consistent
across different cut-off points or predicted risk for CVD. For
comparison, the two Framingham equations overestimated the
risk of CVD in the DIAB-HYCAR cohort by 65% (Anderson
equation) and 99% (D’Agostino equation). Using a cut-off point
for four-year predicted risk of
≥
8% (which is approximately
equivalent to a 10-year predicted risk of 20% and above), the
ADVANCE model would reliably identify 22% of theADVANCE
participants and 39% of the DIAB-HYCAR participants in
whom 48% and 66% of CVD events, respectively, occurred
during follow up. Further intensifying treatment in such groups
on top of any baseline therapy could achieve significant gain in
terms of CVD risk reduction.
Dissemination of the ADVANCE risk model
To facilitate the uptake of the ADVANCE model in clinical
practice, a hand-held calculator and a risk-scoring chart (Fig. 1)
have been developed.
14
Other tools from this model, including
an online calculator, are available on the website of the model to
improve its uptake.
33
Extensive validations have been conducted
to assure that these tools provide estimates similar to those from
the full ADVANCE risk equation.
Performance of existing global risk tools for
cardiovascular risk estimation in diabetics
Two systematic reviews have examined the performance of CVD
risk-evaluation models applicable to people with diabetes.
7,34
The
most recent and comprehensive review identified 45 CVD risk
models applicable to people with diabetes.
7
Of these, 12 were
specifically developed for people with type 2 diabetes (including
the ADVANCE model) and 33 were developed in the general
population, accounting for diabetes as a risk factor. These models
vary greatly in their quality and the methodology used to develop
them.
Only about a third of the existing CVD risk tools applicable
to people with diabetes have been externally validated in a
population with diabetes. The discriminative ability of both
Fig. 1. Major cardiovascular disease points and four-year predicted risk by the ADVANCE model equation.
14
As an illustration of the use of the risk-scoring chart, a male subject, diagnosed with diabetes three years previously at the age of 50 years,
who has a pulse pressure of 50 mmHg and is currently treated for hypertension, also has retinopathy, atrial fibrillation and microalbuminuria,
an HbA
1c
level of 7% and a non-HDL cholesterol level of 3.3 mmol/l, will receive a total score of 13 points: 0 for gender, 3 for age at diagnosis,
1 for known duration, 1 for pulse pressure, 1 for treated hypertension, 1 for retinopathy, 2 for atrial fibrillation, 2 for microabuminuria, and 1 for
HbA
1c
and non-HDL cholesterol level each. A score of 13 points is equivalent to a four-year estimated risk of 6.2%, which is similar to the risk
estimated for the same patient using the full equation.
Step 5
Step 7
Step 8
Step 9
Step 10
Step 6
Step 11
Predicted four-year
risk of major CVD
Step 1
Age at diagnosis (years)
Points
29–34
0
35–39
1
40–44
2
45–50
3
51–56
4
57–62
5
63–68
6
69–74
7
75–80
8
81–86
9
Step 2
Known duration (years)
Points
0
0
1–5
1
6–10
2
11–15
3
16–20
4
21–25
5
26–30
6
31–35
7
36+
8
Step 3
Gender
Points
Men
0
Women
–1
Step 4
Atrial fibrillation
Points
No
0
Old or present
2
Retinopathy
Points
No
0
Yes
1
Pulse pressure, mmHg Points
< 50
0
50–110
1
111 +
2
HbA
1c
(%)
Points
< 6
0
6 – < 9
1
9 +
2
Total points
Four-year risk (%)
5 or less
< 0.5
6
0.5
7
0.7
8
1.0
9
1.4
10
2.1
11
3.0
12
4.3
13
6.2
14
8.9
15
12.6
16
17.8
17
24.7
18
33.7
19
41.9
20
57.8
21
71.4
22
Above 83
Albuminuria
Points
Normoalbuminuria
0
Microalbuminuria
2
Macroalbuminuria
3
Non HDL-C (mmol/l)
Points
< 3
0
3 – < 6
1
6 – < 9
2
9 +
5
Treated hypertension Points
No
0
Yes
1
Sum-up points from steps 1 to 10
Look up predicted four-year risk of major
CVD in the table
