NZ-specific web-based CVD Risk Calculator for people

with Diabetes

Raina Elley, Tim Kenealy, Elizabeth Robinson, Paul Drury, Dale Bramley, Ngaire Kerse, Bruce Arroll, Simon Moyes, Janet Pearson and others

Type 2 Diabetes Prevalence (NZ)

• Approximately 200,000 diagnosed. • Diagnosed (undiagnosed):

– 3.9% (1.8%) for Europeans – 12.0% (3.8%) for Maori– 19.5% (4.0%) for Pacific

Sundborn G, Metcalf P, et al Diabetes Heart and Health Survey (Auckland) 2002-2003, N Z Med J 2007;120(1257):U2607

Diabetes complications:

Importance of CVD in diabetes

• Cardiovascular disease accounts for more than 50% of deaths in people with diabetes.

• People with diabetes are more than twice as likely to have a cardiovascular event, given similar risk profiles.

• People with diabetes are up to 3 times more likely to die after MI than people without diabetes.

http://bestpractice.bmj.com/best-practice/monograph/533.html

Importance of lifestyle interventions e.g. Diabetes Prevention Program

Incidence of diabetes reduced by 17% absolute (37% 20%) in lifestyle group Ref: Knowler WC, N Engl J Med 2002;346(6):393-403

Importance of preventive medications:

Re: Prof. Anthony Rodgers

0.06% 0.07% 0.60%0.00%0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

No Rx

Statin

Statin+

BP

Statin+

BP+Asp

17.5%12.3%

9.2%

25.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

No Rx

Statin

Statin+

BP

Statin+

BP+Asp

Treatment(s)

7̄.5%

5̄.2%

3̄.1%

Overall 1̄5.8%

Abs

olut

e ris

k of

eve

nt o

ver 5

yea

rs

Cardiovascular events Major side effects

CVD risk assessment & management

http://www.nzgg.org.nz

http://www.nzgg.org.nz

CVD risk assessment & management

Assume risk is >20% if:

NZ-adjustment of Framingham risk equation

Diabetes Cohort Study• Aim:

– to derive our own CVD risk equation for people with T2DM of different ethnicities using primary care data

• Methods:– Get-Checked data 2000-2006 linked by eNHI to– NZHIS hospitalisation/mortality data 1988-2008– Outcome: time to 1st hospitalisation or death from CVD

• Analyses:– Cox proportional hazards models to derive the CVD risk

equation

Elley et al, Diabetes Care 2010;33(6):1347-52

North Harbour

Tamaki HealthcareProcare

Ngati Porou Hauora

Pinnacle

Health West

Mangere Comm. Health Trust

Total Healthcare Otara

Counties Manukau CCM

Western BOP PHO

Manawatu, Horowhenua, Tararua Diabetes Trust

Pegasus

Wellington Regional Diabetes Trust

East Health

South Seas health

6 Northland PHOs

Rotorua GP Group

Eastern BOP PHO

48,211 (78%) people without previous CVD

6,479 (17.9%) had first CV event prior to 20 Dec 2007 (1,542 fatal & 4,937 non-fatal)

36,127 from north‡ (Derivation cohort)

62,032 (87%) people with minimum dataset available from at least one assessment

12,626 from south (Validation cohort)

71,570 people assessed 1 January 2000 to 20 December 2005

13,821 (22 %) with previous CVD

48,753 people without previous CV event, after imputation

1,213 died from non-CV causes

2,507 (19.9%) had first CV event prior to 20 Dec 2007 (706 fatal & 1,801 non-fatal)

534 died from non-CV causes

Deriving CV Risk Equation:

Median follow-up 4 years; >10,000 followed for at least 5 years (Northern Cohort)

Importance of glycaemia for CVD

• CVD risk increases with increasing glycaemia (HbA1c)

(after controlling for all other risk factors)

Elley CR, Kenealy T, et al Diabetic Medicine 2008;25(11):1295-301

Risk of CVD for different ethnic groups after controlling for other risk factors

Kenealy , Elley, et al.. Diabetic Medicine. 2008;25:1302-1308.

Importance of renal function (albuminuria)

Kenealy et al, Diabetic Medicine 2008; 25: 1302-1308

• Microalbuminuria: urine albumin creatinine ratio (UACR) ≥ 2.5mg/mmol in men or ≥ 3.5 mg/mmol in women • Macroalbuminuria: UACR ≥ 30 mg/mmol

Albuminuria Hazard Ratio p<0.001

No albuminuria 1.0

Microalbuminuria 1.35 (1.27, 1.44)

Macroalbuminuria 2.29 (2.12, 2.48)

Estimated 5yr CVD risk of 50 yr-old man, non-smoker, SBP 140, TC:HDL ratio 4.5, diabetes duration 5 yrs compared with estimate using the Framingham risk equation

Ethnicity HbA1c Albuminuria Anti-hypFram 5 yr

riskNZ Adjusted

Fram Actual risk

European 7 No No 9% 9% 10%European 7 Micro No 9% 14% 12%European 9 Macro Yes 9% 20% 23%Maori 7 No No 9% 14% 14%Maori 9 Micro No 9% 14% 19%Maori 9 Macro Yes 9% 20% 27%Indian 7 No No 9% 14% 15%Indian 9 Macro Yes 9% 20% 29%Pacific 7 No No 9% 14% 12%Pacific 9 Micro No 9% 14% 17%Pacific 9 Macro Yes 9% 20% 24 %

New NZ Risk equation for type 2 diabetes:

http://www.nzssd.org.nz/cvd/

New NZ Risk equation for type 2 diabetes: compared with Framingham

45 year old Maori man with diabetes, smokes, SBP 130, TC 4, HDL 1

Framingham 5-yr CVD risk: 9%NZ adjustment: 14% 

Plans• Available now for clinicians to use• Further validation with PREDICT and Diabetes

Care Support Services data• Integration into guidelines and PREDICT

software???• Renal Risk Equation derivation

Acknowledgements• Patients and primary care health professionals,

PHOs, Maori Health organisations and Diabetes Trusts that contributed to the study,

• NZHIS, MOH and Sandy Dawson• Funders: HRC, NZSSD and LTU (Dennis Kerrins)• ZEST

Importance of preventive medications: Benefit vs harms in primary prevention (based on CV risk)

11.3%8.4% 7.4%

15.0%

0.0%

5.0%

10.0%

15.0%

20.0%

No Rx

Statin

Statin+BP

Statin+BP+Asp

0.05% 0.15% 0.60%0.00%

0.0%

5.0%

10.0%

15.0%

20.0%

No Rx Statin Statin+BP Statin+BP+Asp

Selak 2010 Journal Primary Health Care, 2 (2), 92-99; Brugts, BMJ 2009;228:b2376; Law, BMJ 2009;228:b1665; Law, BMJ 2003;326:1423-9; ATT Lancet 2009; 373, 1849-60 ; Taylor, Cochrane sys rev, 2011

CVD events Major side effects*

*e.g. man aged 60-69

5-yr CVD risk

Expected CVD events/

5yrs/1000 people

CVD events avoided over 5 years with aspirin (12% proportional reduction)Men Women

50-59 yrs 60-69yrs 70-79 yrs 80-89yrs 50-59yrs 60-69yrs 70-79 yrs 80-89yrs1% 10 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.22% 20 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.43% 30 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.64% 40 4.8 4.8 4.8 4.8 4.8 4.8 4.8 4.85% 50 6 6 6 6 6 6 6 66% 60 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.27% 70 8.4 8.4 8.4 8.4 8.4 8.4 8.4 8.48% 80 9.6 9.6 9.6 9.6 9.6 9.6 9.6 9.69% 90 10.8 10.8 10.8 10.8 10.8 10.8 10.8 10.8

10% 100 12 12 12 12 12 12 12 1213% 130 15.6 15.6 15.6 15.6 15.6 15.6 15.6 15.614% 140 16.8 16.8 16.8 16.8 16.8 16.8 16.8 16.815% 150 18 18 18 18 18 18 18 1816% 160 19.2 19.2 19.2 19.2 19.2 19.2 19.2 19.217% 170 20.4 20.4 20.4 20.4 20.4 20.4 20.4 20.418% 180 21.6 21.6 21.6 21.6 21.6 21.6 21.6 21.620% 200 24 24 24 24 24 24 24 24

    Estimated harm in 5 years [ATT], n  Serious GI/extra-cranial bleed

2.1 4.5* 9.6* 20.9* 1.0 2.3* 4.8* 10.4**Modelled on harm increasing 2.15 x per decade

Benefits vs harms in primary prevention: men 80-89 years

11.3%8.4% 7.4%

15.0%

0.0%

5.0%

10.0%

15.0%

20.0%

No Rx

Statin

Statin+BP

Statin+BP+Asp

0.05% 0.15%

2.24%

0.00%0.0%

5.0%

10.0%

15.0%

20.0%

No Rx Statin Statin+BP Statin+BP+Asp

Major side effectsCVD events

Selak 2010 Journal Primary Health Care, 2 (2), 92-99; Brugts, BMJ 2009;228:b2376; Law, BMJ 2009;228:b1665; Law, BMJ 2003;326:1423-9; ATT Lancet 2009; 373, 1849-60 , Taylor, Cochrane sys rev, 2011