Simultaneous derivation, validation, and comparison of predictor hazard ratios for cardiovascular risk prediction equations in patients with diabetes from high versus non-high income countries: cohort study

Q: What are the key findings of this study?

The hazard ratio for cardiovascular events per 10 years of age was markedly higher in Chinese women with diabetes (HR 2.51) compared to New Zealand women (HR 1.61), necessitating age coefficient replacement for accurate risk prediction.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Type 2 diabetes without previous cardiovascular disease (n=94516). Intervention: Age (per 10 years) vs. Baseline age. Primary outcome: First cardiovascular events (hazard ratio for age per 10 years in Chinese women) (HR 2.51, 95% CI 2.32 to 2.72, p=<0.001).

Q: What does this research mean for the field?

Applying cardiovascular risk prediction equations derived from high-income countries to populations in non-high-income countries introduces systematic errors primarily due to differing age effects, which can be corrected by updating specific predictor coefficients rather than relying on standard recalibration. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To evaluate the generalisability of cardiovascular disease risk predictor effects between high income and non-high income countries, derive comparable risk equations, and optimize prediction strategies.

Jingyuan Liang; Yeunhyang Choi; Peng Shen; Linda Wells; Katrina Poppe; Zhangping Fu; Matire Harwood; Xiaofei Liu; Sue Crengle; Ting Wang; Corina Grey; Hongbo Lin; Suneela Mehta; Xun Tang; Rod Jackson; Pei Gao

doi:10.1136/bmj-2026-100535

September 11, 2026BMJOpen Access

Simultaneous derivation, validation, and comparison of predictor hazard ratios for cardiovascular risk prediction equations in patients with diabetes from high versus non-high income countries: cohort study

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Key result

Age coefficient replacement improves CV risk prediction in Chinese diabetic women with ~151% higher risk per decade.

HR 2.51
95% CI 2.32 to 2.72
P<0.001
n=94,516

Why the study?

To directly test the generalisability of cardiovascular disease risk predictor effects between populations in a high income versus non-high income country, derive comparable equations, and identify more effective cross-population prediction strategies.

Does updating key predictor coefficients, particularly age, improve the accuracy of high-income country derived cardiovascular risk prediction equations when applied to a non-high income country population with diabetes?

Key Points

To evaluate the generalisability of cardiovascular disease risk predictor effects between high income and non-high income countries, derive comparable risk equations, and optimize prediction strategies.
Analyzed electronic health records from equivalent cohorts of patients aged 30-74 years with diabetes and no prior cardiovascular disease in New Zealand (n=47,958; 2004-2018) and China (n=46,558; 2010-2018).
Derived sex-specific five-year risk equations featuring 16 predictors to estimate first cardiovascular events and compared predictor hazard ratios across populations.
Applied the New Zealand models to the Chinese cohort, evaluating model performance before and after standard recalibration, followed by updating coefficients for predictors with statistically significant differences.
First cardiovascular events occurred in 5622 (11.7%) New Zealand participants and 3650 (7.8%) Chinese participants.
Hazard ratios were generally comparable across countries but differed markedly for age, particularly among women (HR 1.61, 95% CI 1.51 to 1.71 per 10 years in New Zealand vs HR 2.51, 95% CI 2.32 to 2.72 per 10 years in China).
Standard recalibration failed to achieve adequate calibration in the Chinese cohort (expected to observed ratio: 0.938 in men, 0.809 in women), whereas substituting Chinese age coefficients substantially improved performance (expected to observed ratio: 1.027 in men, 1.025 in women).

Study Design

Type

Cohort (n=94,516)

Multicenter

Yes

Structured PICO

Does updating key predictor coefficients, particularly age, improve the accuracy of high-income country derived cardiovascular risk prediction equations when applied to a non-high income country population with diabetes?

P

Population

94,516 adults aged 30-74 years with type 2 diabetes and no prior cardiovascular disease or severe renal impairment from New Zealand and China, followed for up to 5 years.

E

Exposure

New Zealand-derived cardiovascular risk prediction equations with age coefficient replacement

C

Comparator

Original New Zealand-derived cardiovascular risk prediction equations and standard recalibrated equations

O

Outcome

First non-fatal (admission to hospital) or fatal cardiovascular disease event, including atherosclerotic disease (coronary heart disease, cerebrovascular disease, and peripheral vascular disease), heart failure, and haemorrhagic strokecomposite

Main Result

Hazard Ratio: 2.51 (95% CI 2.32–2.72)

p-value: p=<0.001

Limitations

Wider applicability requires further investigation in other settings and populations
Socioeconomic status indicator used in the previous New Zealand equations was not included due to lack of comparable variables in the Chinese cohort
Potential differences between predictor and outcome definitions in the datasets from high income and non-high income countries

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Answers are grounded in this paper and cite their sources.

Implication

Applying high-income country derived CVD risk prediction equations to non-high income populations with diabetes requires updating key predictor coefficients, particularly age, to achieve accurate risk stratification.

Abstract

OBJECTIVE: To directly test the generalisability of cardiovascular disease (CVD) risk predictor effects across populations in a high income versus non-high income country, derive comparable risk equations, and identify more effective strategies for prediction across populations. DESIGN: Population based cohort study. SETTING: Primary prevention cohorts in New Zealand and China. PARTICIPANTS: Equivalent New Zealand and Chinese cohorts of people aged 30-74 years with diabetes and no CVD based on electronic health records. MAIN OUTCOME MEASURES: Country specific five year equations were derived using standardised methods to predict first cardiovascular events; predictor hazard ratios were compared. New Zealand equations were applied to the Chinese cohort, with performance assessed before and after standard recalibration, followed by the updating of predictor hazard ratios that differed statistically significantly. RESULTS: Between 2004 and 2018, 47 958 New Zealand participants had 5622 (11.7%) first CVD events. Between 2010 and 2018, 46 558 Chinese participants had 3650 (7.8%) first CVD events. Sex specific equations included 16 predictors. Hazard ratios for most predictors were similar between New Zealand and Chinese equations but differed markedly for age (eg, women: 1.61, 95% confidence interval 1.51 to 1.71 per 10 years in New Zealand, 2.51 (2.32 to 2.72) per 10 years in China). Standard recalibration of New Zealand equations did not improve calibration in the Chinese cohort (expected to observed ratio: 0.938 in men, 0.809 in women). Replacing New Zealand age coefficients with Chinese coefficients noticeably improved calibration (expected to observed ratio 1.027 in men, 1.025 in women). CONCLUSIONS: Applying a high income country derived CVD risk prediction equation to a population from a non-high income country with diabetes may introduce systematic errors, primarily driven by differences in the effect of age. Moving beyond simple recalibration to updating key predictor coefficients, particularly age, should be considered for more accurate risk stratification. This study highlights potential limitations of high income country equation updating practices and proposes a feasible approach to improve their accuracy when used in populations from non-high income countries.

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Cite This Study

Liang et al. (2026) conducted a cohort in Type 2 diabetes without previous cardiovascular disease (n=94,516). Age (per 10 years) vs. Baseline age was evaluated on First cardiovascular events (hazard ratio for age per 10 years in Chinese women) (HR 2.51, 95% CI 2.32 to 2.72, p=<0.001). The hazard ratio for cardiovascular events per 10 years of age was markedly higher in Chinese women with diabetes (HR 2.51) compared to New Zealand women (HR 1.61), necessitating age coefficient replacement for accurate risk prediction.

synapsesocial.com/papers/6aa7b3060926e14a848b1a8f https://doi.org/10.1136/bmj-2026-100535

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Simultaneous derivation, validation, and comparison of predictor hazard ratios for cardiovascular risk prediction equations in patients with diabetes from high versus non-high income countries: cohort study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Simultaneous derivation, validation, and comparison of predictor hazard ratios for cardiovascular risk prediction equations in patients with diabetes from high versus non-high income countries: cohort study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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