新西兰奥克兰大学Rod Jackson团队进行了广泛筛查前后2型糖尿病心血管风险预测的推导和验证研究。2021年6月2日，《柳叶刀》杂志发表了该成果。
直到最近，世界范围内的大多数糖尿病患者都被诊断为有症状的心血管疾病，这意味着大多数患者都应该接受心血管疾病预防药物的治疗。新西兰进行了一项世界首创的国家计划，导致2016年约90%的符合条件的成年人接受糖尿病筛查，高于2012年的50%，确定了许多近期发病的无症状糖尿病患者。研究组假设在广泛筛查之前得出的心血管风险预测方程会显著高估筛查患者的风险。
2004年10月27日至2016年12月30日，研究组进行了一项40万人的初级保健队列研究，这些新西兰人年龄在30-74岁之间，患有2型糖尿病，没有已知的心血管疾病、心力衰竭或严重的肾功能损害。使用Cox回归模型建立估计5年心血管疾病风险的性别特异性方程，其中有18个预先指定的预测因子，包括糖尿病相关指标和肾功能指标。将方程性能与新西兰糖尿病队列研究中得出的等效方程进行比较。
46652名参与者被纳入1个糖尿病亚组，其中4114例在随访期间首次发生心血管事件（平均5.2年）。14829例（31.8%）在基线检查时没有口服降糖药物或胰岛素。新方程估计的5年心血管风险中位数女性为4.0%，男性为7.1%。旧方程估计女性心血管风险中位数为14.2%，是新方程的3倍，男性为17.1%，是新方程的2倍。新方程的模型选择性能度量显著优于旧方程。
研究组发现最近广泛的糖尿病筛查已经从根本上改变了新西兰糖尿病患者的心血管风险状况。许多患者的肾功能正常，未服用降糖药物，心血管风险较低。新型糖尿病人群的心血管风险预测方程可进行更准确的预估，同时降低用药成本。
附：英文原文
Title: Cardiovascular risk prediction in type 2 diabetes before and after widespread screening: a derivation and validation study
Author: Romana Pylypchuk, Sue Wells, Andrew Kerr, Katrina Poppe, Matire Harwood, Suneela Mehta, Corina Grey, Billy P Wu, Vanessa Selak, Paul L Drury, Wing Cheuk Chan, Brandon Orr-Walker, Rinki Murphy, Jim Mann, Jeremy D Krebs, Jinfeng Zhao, Rod Jackson
Issue&Volume: 2021-06-02
Abstract:
Background
Until recently, most patients with diabetes worldwide have been diagnosed when symptomatic and have high cardiovascular risk, meaning most should be prescribed cardiovascular preventive medications. However, in New Zealand, a world-first national programme led to approximately 90% of eligible adults being screened for diabetes by 2016, up from 50% in 2012, identifying many asymptomatic patients with recent-onset diabetes. We hypothesised that cardiovascular risk prediction equations derived before widespread screening would now significantly overestimate risk in screen-detected patients.
Methods
New Zealanders aged 30–74 years with type 2 diabetes and without known cardiovascular disease, heart failure, or substantial renal impairment were identified from the 400000-person PREDICT primary care cohort study between Oct 27, 2004, and Dec 30, 2016, covering the period before and after widespread screening. Sex-specific equations estimating 5-year risk of cardiovascular disease were developed using Cox regression models, with 18 prespecified predictors, including diabetes-related and renal function measures. Equation performance was compared with an equivalent equation derived in the New Zealand Diabetes Cohort Study (NZDCS), which recruited between 2000 and 2006, before widespread screening.
Findings
46652 participants were included in the PREDICT-1° Diabetes subcohort, of whom 4114 experienced first cardiovascular events during follow-up (median 5·2 years, IQR 3·3–7·4). 14829 (31·8%) were not taking oral hypoglycaemic medications or insulin at baseline. Median 5-year cardiovascular risk estimated by the new equations was 4·0% (IQR 2·3–6·8) in women and 7·1% (4·5–11·2) in men. The older NZDCS equation overestimated median cardiovascular risk by three times in women (median 14·2% [9·7–20·0]) and two times in men (17·1% [4·5–20·0]). Model and discrimination performance measures for PREDICT-1° Diabetse equations were also significantly better than for the NZDCS equation (eg, for women: R2=32% [95% CI 29–34], Harrell's C=0·73 [0·72–0·74], Royston's D=1·410 [1·330–1·490] vs R2=24% [21–26], C=0·69 [0·67–0·70], and D=1·147 [1·107–1·187]).
Interpretation
International treatment guidelines still consider most people with diabetes to be at high cardiovascular risk; however, we show that recent widespread diabetes screening has radically changed the cardiovascular risk profile of people with diabetes in New Zealand. Many of these patients have normal renal function, are not dispensed glucose-lowering medications, and have low cardiovascular risk. These findings have clear international implications as increased diabetes screening is inevitable due to increasing obesity, simpler screening tests, and the introduction of new-generation glucose-lowering medications that prevent cardiovascular events. Cardiovascular risk prediction equations derived from contemporary diabetes populations, with multiple diabetes-related and renal function predictors, will be required to better differentiate between low-risk and high-risk patients in this increasingly heterogeneous population and to inform appropriate non-pharmacological management and cost-effective targeting of expensive new medications.
DOI: 10.1016/S0140-6736(21)00572-9
Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00572-9/fulltext
LANCET：《柳叶刀》，创刊于1823年。隶属于爱思唯尔出版社，最新IF：202.731
官方网址：http://www.thelancet.com/
投稿链接：http://ees.elsevier.com/thelancet
本期文章：《柳叶刀》：Online/在线发表
