Lifetime Cardiovascular Disease Risk by Coronary Artery Calcium Score in Individuals With and Without Diabetes: An Analysis From the Multi-Ethnic Study of Atherosclerosis

Bart S Ferket*, M G Myriam Hunink, Umesh Masharani, Wendy Max, Joseph Yeboah, Gregory L Burke, Kirsten E Fleischmann

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

8 Citations (Scopus)


OBJECTIVE To assess lifetime cardiovascular disease (CVD) risk by coronary artery calcium (CAC) score in individuals with diabetes from the Multi-Ethnic Study of Atherosclerosis (MESA) and compare risk with that in individuals without diabetes. RESEARCH DESIGN AND METHODS We developed a microsimulation model with well, diabetes, post-CVD, and death health states using multivariable time-dependent Cox regression with age as time scale. We initially used 10-year follow-up data of 6,769 MESA participants, including coronary heart disease (CHD) (n = 272), heart failure (n = 201), stroke (n = 186), and competing death (n = 619) and assessed predictive validity at 15 years. We externally validated the model in matched National Health and Nutrition Examination Survey (NHANES) participants. Subsequently, we predicted CVD risk until age 100 years by diabetes, 10-year pooled cohort equations risk, and CAC score category (0, 1–100, or 100+). RESULTS The model showed good calibration and discriminative performance at 15 years, with discrimination indices 0.71–0.78 across outcomes. In the NHANES cohort, predicted 15-year mortality risk corresponded well with Kaplan-Meier risk, espe-cially for those with diabetes: 29.6% (95% CI 24.9–34.8) vs. 32.4% (95% CI 27.2–37.2), respectively. Diabetes increased lifetime CVD risk, similar to shifting one CAC category upward (from 0 to 1–100 or from 1–100 to 100+). Patients with diabetes and CAC score of 0 had a lifetime CVD risk that overlapped with that of individuals without diabetes who were at low 10-year pooled cohort equations risk (<7.5%). CONCLUSIONS Patients with diabetes carry a spectrum of CVD risk. CAC scoring may improve decisions for preventive interventions for patients with diabetes by better delin-eating lifetime CVD risk.

Original languageEnglish
Pages (from-to)975-982
Number of pages8
JournalDiabetes Care
Issue number4
Publication statusPublished - 1 Apr 2022

Bibliographical note

Funding Information:
Acknowledgments. The authors thank the other investigators, the staff, and the participants of the MESA study for their valuable contributions. This article was prepared using MESA research materials obtained from the National Heart, Lung, and Blood Institute and has been reviewed by MESA for scientific content and consistency of data interpretation with previous MESA publications. A full list of participating MESA investigators and institutions can be found at Funding. MESA was supported by contracts HHSN268201500003I, N01-HC-95159, N01-HC-95 160, N01-HC-95161, N01-HC-95162, N01-HC-951 63, N01-HC-95164, N01-HC-95165, N01-HC-9516 6, N01-HC-95167, N01-HC-95168, and N01-HC-95169 from the National Heart, Lung, and Blood Institute, National Institutes of Health, and by grants UL1-TR-000040, UL1-TR-001079, and UL1-TR-001420 from the National Center for Advancing Translational Sciences. B.S.F., M.G.M.H., U.M., W.M., and K.E.F. were supported by American Diabetes Association grant 1-18-ICTS-041. The American Diabetes Association had no role in the design or conduct of the study, collection, management, analysis, or interpretation of the data, pr eparation, review, or approval of the manuscript,

Funding Information:
or the decision to submit the manuscript for publication. Duality of Interest. M.G.M.H. receives royalties from Cambridge University Press for a textbook on medical decision making, reimbursement of expenses from the European Society of Radiology (ESR) for work on ESR guidelines for imaging referrals, reimbursement of expenses from the European Institute for Biomedical Imaging Research for membership on the scientific advisory board, and additional research funding from the Netherlands Organization for Health Research and Development, the German Innovation Fund, a Netherlands Educational Grant (Studie Voor-schot Middelen), and the Gordon and Betty Moore Foundation. No other potential conflicts of interest relevant to this article were reported. Author Contributions. B.S.F. and M.G.M.H. performed statistical analysis. K.E.F. obtained funding. All authors contributed to study conception and design, acquisition, analysis, or interpretation of data, critical revision of the manuscript for important intellectual content, and provision of administrative, technical, or material support. B.S.F. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Prior Presentation. Parts of this study were presented in abstract form at the American Diabetes Association’s 79th Scientific Sessions, 7–11 June 2019, and the Society of Medical Decision Making’s 42nd Annual North American Meeting, 6–27 October 2020.

Publisher Copyright:
© 2022, American Diabetes Association Inc.. All rights reserved.


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