VOLUME 10 NUMBER 2 • JUNE 2013
63
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
Dissemination of the ADVANCE risk model
To facilitate the uptake of the ADVANCE model in clinical practice,
a handheld calculator and a risk scoring chart (Figure 1) have been
developed.
14
Other tools from this model, including an online
calculator are available at 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 people with diabetes
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 risk CVD
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 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
to 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 prediction models also showed a low-
to-acceptable discrimination and a poor calibration. Although the
discriminative power of UKPDS engines was acceptable, it has a
poor calibration and a tendency toward systematic overestimation
Figure 1.
Major cardiovascular disease points and 4-year predicted risk by the ADVANCE Model equation.
14
Step 1
Step 5
Step 11
Age at diagnosis, y
Points
Retinopathy
Points
Sum up points from steps 1 through 10
Look up predicted 4-year risk of major CVD
in the table
29-34
0
No
0
35-39
1
Yes
1
40-44
2
45-50
3
Step 6
51-56
4
Treated hypertension
Points
57-62
5
No
0
63-68
6
Yes
1
69-74
7
75-80
8
Step 7
81-86
9
Pulse pressure, mmHg
Points
< 50
0
Predicted 4-year risk of Major CVD
Step 2
50-110
1
Known duration, y
Points
111 +
2
0
0
Total points
4-year risk, %
1-5
1
Step 8
5 or less
< 0.5%
6-10
2
HbA
1c
Points
6
0.5%
11-15
3
< 6%
0
7
0.7%
16-20
4
6 - < 9
1
8
1.0%
21-25
5
9 +
2
9
1.4%
26-30
6
10
2.1%
31-35
7
Step 9
11
3.0%
36+
8
Albuminuria
Points
12
4.3%
Normoalbuminuria
0
13
6.2%
Step 3
Microalbuminuria
2
14
8.9%
Sex
Points
Macroalbuminuria
3
15
12.6%
Men
0
16
17.8%
Women
-1
Step 10
17
24.7%
Non HDL-c, mmol/L
Points
18
33.7%
Step 4
< 3
0
19
41.9%
Atrial fibrillation
Points
3 - < 6
1
20
57.8%
No
0
6 - < 9
2
21
71.4%
Old or present
2
9 +
5
22
Above 83%
As an illustration of the use of the risk scoring chart, a male subject, diagnosed with diabetes 3 years previously at the age of 50, who has a pulse pressure of
50 mmHg and is currently treated for hypertension; also has retinopathy, atrial fibrillation and microalbuminuria, an HbA
1c
of 7% and a non-HDL cholesterol
of 3.3 mmol.L
-1
; will receive a total score of 13 points: 0 for sex, 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 each. A score of 13 points is equivalent to a 4-year
estimated risk of 6.2%, which is similar to the risk estimated for the same patient using the full equation.
