CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 9/10, October/November 2013
380
AFRICA
diabetes-specific CVD prediction models and general population
prediction models that use diabetes status as a predictor was
generally acceptable to good (i.e.
C
-statistic
≥
0.70). The
discrimination of prediction models designed for the general
population was moderate (
C
-statistic: 0.59–0.80) and their
calibration generally poor.
The most commonly validated models were the general
population-based Framingham cardiovascular risk equations and
the diabetes-specific UKPDS risk engines. The Framingham
predictionmodels also showed a low-to-acceptable discrimination
and a poor calibration. Although the discriminative power of
UKPDS engines was acceptable, it had a poor calibration and a
tendency toward systematic overestimation of risk, particularly
in recent cohorts. The models with best external validity were
more contemporary but these had been validated in other patient
populations only once.
7
Conclusion
The quest for the appropriate approaches to assess cardiovascular
risk and thus prevent vascular complications in individuals
with diabetes is a continuing pursuit. Diabetes mellitus is not
a cardiovascular risk equivalent in all circumstances. The CVD
risk is not uniformly distributed in individuals with diabetes,
but rather follows a gradient. Adequately capturing this gradient
depends on the combination of individual risk factors.
Global risk assessment appears to be the way forward for
managing CVD risk among people with diabetes. Both the
ADVANCE and subsequent studies have provided evidence
that existing popular models derived from older cohorts were
less accurate for cardiovascular risk evaluation in contemporary
population with diabetes.
7
The recognition of this non-optimal
performance and other limitations of existing models have
stimulated efforts to develop new cardiovascular risk models
(including the ADVANCE model
14
) with improved predictive
accuracy for people with diabetes.
The ADVANCE model continues to enjoy the unique property
that it was developed from a contemporary multinational cohort
of people with diabetes, and has been successfully validated in
another recent multinational cohort of individuals with diabetes.
Inclusion of participants from developing countries in the
ADVANCE cohort highlights the potential of the ADVANCE
risk model for assisting cardiovascular risk-stratification efforts
in many settings around the world.
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