nz-specific web-based cvd risk calculator for people with diabetes
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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
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: 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