Cardiovascular risk profile in subjects with diabetes: Is SCORE2-Diabetes reliable?

Abstract

Background: People living with type 2 diabetes (T2D) are at a two- to four-fold higher risk of developing cardiovascular disease (CVD) compared with those without T2D, making early assessment of their CV risk essential. European Society of Cardiology (ESC) has developed a new model to estimate 10-year CV risk in people with T2D aged ≥ 40 years: SCORE2-Diabetes. Despite its advantages, several aspects remain to be clarified. This study evaluated the association between CV risk stratified by SCORE2-Diabetes and early CV damage assessed through arterial stiffness, intima-media thickness (IMT), and carotid atherosclerosis. Additionally, it examined the agreement between risk stratification by SCORE2 and SCORE2-Diabetes and their concordance with vascular damage.

Methods: Pulse wave velocity (PWV), IMT, and carotid atherosclerosis were assessed in 179 individuals with T2D aged 40-69 years, categorized into SCORE2-Diabetes risk groups: Low (n = 20), Moderate (n = 29), High (n = 44), and very high (n = 37). Patients with a history of atherosclerotic cardiovascular disease (ASCVD) or severe target organ damage (TOD) constituted another group (ASCVD/TOD, n = 49).

Results: PWV was significantly increased from Low to very high and ASCVD/TOD groups (7.2 ± 1.1, 8.7 ± 1.9, 9.8 ± 2.3, 12.8 ± 5.1 and 11.5 ± 3.8 m/s, respectively). Similarly, IMT showed a stepwise increase with risk class (0.68 ± 0.11, 0.78 ± 0.13, 0.83 ± 0.12, 0.86 ± 0.19 and 0.87 ± 0.15 mm, respectively). Patients in very high or ASCVD/TOD group showed a higher prevalence of carotid atherosclerosis than other groups (0%, 17.24%, 11.40%, 37.83% and 40.81%, respectively). No significant differences were found between the very high and ASCVD/TOD groups in any parameter. The correlation between PWV values and increasing CV risk was stronger for SCORE2-Diabetes than for SCORE2. ROC curve analysis showed SCORE2-Diabetes had superior predictive performance for carotid atherosclerosis and high PWV compared to SCORE2 (p = 0.048).

Conclusions: Higher PWV, IMT, and carotid atherosclerosis prevalence were associated with increasing CV risk stratified by SCORE2-Diabetes, with no significant differences between the very high and ASCVD/TOD groups. SCORE2-Diabetes demonstrated a better identification of preclinical vascular damage compared to SCORE2, supporting its use as a reliable tool for identifying vascular damage in T2D patients without ASCVD or TOD.

Keywords: Arterial stiffness; Atherosclerosis; Cardiovascular risk; Intima-media thickness; SCORE2-Diabetes; Type 2 diabetes.

Fig. 1

Vascular profile of the study population according to CV risk classes. Box plots showing PWV significantly increased from low to very high and ASCVD/TOD groups. Similar results for IMT, with progressively higher values as the risk classes increase. No statistically significant difference was found in the considered parameters between the very high risk group and ASCVD/TOD group. *P < 0.05 versus low group; #P < 0.05 versus Moderate group; °P < 0.05 versus high group. NS, not significant difference

Fig. 2

PWV distribution in risk classes according to SCORE 2 Diabetes. The boxplot shows the distribution of PWV across different cardiovascular risk classes stratified according to SCORE2 Diabetes. ASCVD/TOD: atherosclerotic cardiovascular disease or severe target organ damage. Spearman’s correlation (R = 0.48, p < 0.05) confirmed a positive association between PWV and increasing risk categories

Fig. 3

Comparison of risk stratification between SCORE2 and SCORE2-Diabetes in the study population. ASCVD/TOD: atherosclerotic cardiovascular disease or severe target organ damage. Among the 100 patients initially classified as low or moderate risk by SCORE2, 67 were reclassified as high or very high risk using SCORE2-Diabetes, highlighting a significant reclassification that may impact clinical decision-making

Fig. 4

The boxplot shows the distribution of PWV across different cardiovascular risk classes stratified according to SCORE2. ASCVD/TOD: atherosclerotic cardiovascular disease or severe target organ damage. Spearman’s correlation (R = 0.28, p < 0.05) confirmed a positive association between PWV and increasing risk categories

Fig. 5

ROC curves illustrate the performance of SCORE2 and SCORE2 Diabetes in predicting cardiovascular risk according to presence of carotid plaque (atherosclerosis prediction)

Fig. 6

ROC curves illustrate the performance of SCORE2 and SCORE2 Diabetes in predicting cardiovascular risk according to arterial stiffness results (prediction of PWV > 9.25)