Cardiovascular disease risk prediction in type 1 diabetes over 30 years: the DCCT/EDIC Study

Cardiovascular disease (CVD) limits quality of life and survival and its accelerated course in type 1 diabetes (T1D) may challenge standard risk prediction models. We assessed 10-year CVD risk performance of the Framingham Risk Score (FRS), ASCVD Risk Estimator Plus (ASCVD), AHA PREVENT, and Steno Type 1 Risk Engine (ST1RE) prediction models over 30 years in a T1D population, and evaluated the role of coronary artery calcification (CAC) and HbA1c as risk-enhancers. Analysis included 1,311 participants followed for 30 years during the Epidemiology of Diabetes Interventions and Complications (EDIC) study. Model-predicted CVD risk calculated at successive 10-year timeframes over 30 years; calibration and c-statistics were assessed for each period. At EDIC Year 20-30, the 10-year observed CVD risk was 1.43 (95% CI 1.36-1.49), 2.69 (95% CI 2.55-2.86), and 2.40 (95% CI 2.30-2.51) times higher than predicted by FRS, ASCVD and PREVENT, respectively, and lower than predicted by ST1RE (RR 0.61-0.87 at all timepoints). Discrimination was modest (C-statistic 0.54-0.64) across models. Among individuals classified as low or moderate predicted risk, the observed risk among those with CAC ≥100 Agatston units was comparable to the high-risk category; the observed risk among those with CAC=0 was comparable to the low-risk category. HbA1c similarly enhanced risk of CVD. In T1D, traditional CVD risk prediction models have limited performance. Risk enhancers improved risk classification. More accurate, tailored risk estimation is needed to identify early risk mitigation interventions in T1D. clinicaltrials.gov NCT00360815 and NCT00360893 What is currently known about this topic? Cardiovascular disease (CVD) limits quality of life, and its distinct pathophysiology in type 1 diabetes (T1D) may challenge risk prediction models. What is the key research question? Are CVD risk prediction tools accurate among populations with T1D? What is new? At EDIC Year 20–30, the 10-year observed CVD risk was 1.43, 2.69, and 2.40 times higher than predicted by Framingham Risk Score, ASCVD Risk Estimator Plus, and PREVENT, respectively, and lower than predicted by Steno Type 1 Risk Engine (ST1RE). All models except ST1RE underpredicted risk in females. How might this study influence clinical practice? Inclusion of CAC and HbA1c as risk enhancers improve the performance of 10-year CVD risk predictors.