VOLUME 11 NUMBER 3 • SEPTEMBER 2014
121
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
The ADVANCE cardiovascular risk model and current
strategies for cardiovascular disease risk evaluation in
people with diabetes
Andre Pascal Kengne
Correspondence to: Andre Pascal Kengne
South African Medical Research Council, Tygerberg, Cape Town, South Africa
e-mail:
Previously published in
Cardiovasc J Afr
2013;
24
(9): 351
S Afr J Diabetes Vasc Dis
2014;
11
: 121–125
Abstract
Purpose:
To critically examine existing approaches to
cardiovascular disease (CVD) risk evaluation in people with
diabetes, and discuss the use of accurate and validated
absolute CVD risk tools as an appropriate basis for CVD
prevention in people with diabetes.
Methods: This was a narrative review using evidence from
the ADVANCE study and all relevant publications identified
via PubMed MEDLINE.
Results:
There is sufficient evidence that diabetes does not
confer a CVD risk equivalent to that in non-diabetic people
with existing CVD in all circumstances. In people with
diabetes, CVD risk follows a gradient. Reliably capturing this
gradient depends on an adequate combination of several
risk factors. Many global CVD risk tools applicable to people
with diabetes have been developed. Those derived from
older cohorts are less accurate in contemporary populations
and many newer tools have not been tested. The ADVANCE
risk engine, recently developed from the large multinational
ADVANCE study, showed acceptable performance on the
ADVANCE population and largely outperformed the popular
Framingham risk equation when tested on the multinational
DIAB-HYCAR cohort of people with type 2 diabetes.
Conclusions:
The high-risk status conferred by diabetes does
not preclude estimation of absolute CVD risk using tools
such as the ADVANCE risk engine and its use as the basis
for initiating and intensifying CVD preventative measures.
Adopting such an accurate and validated tool will likely
improve prescriptions and outcomes of diabetes care.
Keywords:
diabetesmellitus, cardiovascular disease, risk evaluation,
ADVANCE, absolute risk
Cardiovascular disease (CVD), the leading global killer, is
multifactorial by nature. No single risk factor taken alone is able to
distinguish people who will go on to develop a cardiovascular event
from those who will not. This consideration forms the basis of the
contemporary multifactorial approaches to CVD risk evaluation and
reduction.
A key aim of CVD risk evaluation is to identify those in the
population who’s health outcomes can be modified by performing
more medical tests, starting treatments to reduce the level of
risk factors or increasing the doses of prescribed riskreducing
therapies.
1,2
Estimated risks are also used to educate patients about
their chances of experiencing a cardiovascular event within a given
time period (for example, five or 10 years).
Equipped with this knowledge, patients are more likely to be
motivated to adopt healthy lifestyle measures and/or to observe
prescribed risk-modifying treatments. These patients are also
more likely to regularly report back to their healthcare provider for
monitoring and adaptation of treatments, to lower and maintain
their risk factors at optimal levels.
Concerning CVD in people with diabetes, healthcare providers
who see these patients on a routine basis are interested in gauging
the chances of their patients developing any major CVD event over
a reasonable period of time (often five to 10 years), and not just
specific components such as stroke or myocardial infarction. These
busy healthcare providers are also interested in assessing the CVD
risk of their patients using accurate and validated global CVD risk-
evaluation tools.
3-5
In the general population, efforts to develop reliable tools for
evaluating CVD risk based on a combination of several risk factors
have paralleled efforts to improve our understanding of the
determinants of CVD and more efficient ways to control them.
6
These efforts were initially led by the Framingham investigators,
and more recently by investigators from other parts of the world.
6,7
The first attempts to develop such tools from the Framingham
study date back to the year 1967.
8
These first tools, however, did
not account for diabetes status or for any other indicator of chronic
hyperglycaemia.
Although many subsequent Framingham tools took diabetes
status into consideration, the uptake of the Framingham tools in
people with diabetes around the world has remained very limited,
resulting in the adoption of multivariable CVD tools in people with
diabetes to lag behind the general population. One reason was the
lack of trust among researchers on the validity of the Framingham
tools in people with diabetes, due to the relatively small number
of people with diabetes in the Framingham cohort, and the non-
inclusion of other indicators of exposure to chronic hyperglycaemia
in the Framingham tools.
9
Another major reason was the publication in the late 1990s of
a study from Finland suggesting that people with diabetes but no
history of cardiovascular disease had a future risk of CVD similar
to the risk of non-diabetic people who have survived a CVD event
in the past.
10
This study inspired the concept of diabetes as a ‘CVD
risk equivalent’, based on which people with diabetes should be
treated with cardiovascular risk-reducing therapies such as statins
or aspirin, without taking into consideration their absolute CVD
risk levels.
However, the concept of diabetes as a CVD risk equivalent has
been losing ground in recent years, with the accumulating evidence
challenging its validity in all circumstances,
11
and supporting the
