The Acute Coronary Syndrome Risk in Medically Managed Subjects with Type 2 Diabetes Mellitus - Is the ASCVD Risk Score Failing Here?

Objectives. The risk of acute coronary syndrome (ACS) is high in subjects with type 2 diabetes mellitus (T2DM). The current management algorithm focuses on atherosclerotic cardiovascular (ASCVD) risk score to stratify this risk. However, in medically managed subjects, this algorithm may not be accurate. The current study compares the ASCVD risk score calculated in a subset of the Indian population with T2DM under medical supervision and the actual incidence of ACS. It also compared the ASCVD risk scores in cases with T2DM who developed ACS to controls who did not and tried to estimate whether ASCVD risk score is different in the two subsets, thereby evaluating the utility of ASCVD risk score in predicting ACS in subjects with T2DM on medical management. The impact of other factors like hypertension, dyslipidaemia, family history of ACS, and duration of T2DM on the development of ACS was also investigated. Methodology. This is an electronic medical record (EMR) based case -control study. Only records of subjects with T2DM where details of age, sex, body mass index, blood pressure, duration of diabetes, family history of ACS, lipid profile, renal and liver function tests (in those affected with ACS, the details need to be within 6 months prior to the ACS) were included. The incidence of ACS was calculated in the selected records. The records of subjects who developed ACS were compared with age and sex -matched subjects who did not develop ACS. Data are summarized as median and interquartile range (IQR). Wilcoxon rank -sum test was used for checking differences in continuous variables and Pearson's Chi -squared test for categorical data. Univariate and multivariate logistic regression analyses were used to check the effect of ASCVD scores and other variables on the occurrence of ACS. Statistical data analyses were performed using JASP, version 0.16.4 (JASP Team [2022]) for MS Windows. Results. Of the 1226 EMRs included in the analysis, 207 had ACS. The actual incidence of ACS was 16.85 percent in 6 years which was more than the mean predicted 10 -year incidence of 14.56 percent (p <0.05). The cases were age and sex -matched with controls and the ASCVD incidence was estimated in the two groups. The mean ASCVD score in the cases was 14.565 +/- 8.709 (Min: 1.5, Max: 38.3) and controls 13.114 +/- 8.247 (Min: 1.4, Max: 45). We conclude that the ASCVD risk score may not accurately predict the ACS risk (may underestimate) and may be similar in those who developed ACS and those who did not. The chance of development of ACS increases with raised systolic blood pressure (per mmHg rise OR: 1.04, 95% CI: 1.03, 1.06; p <0.001), positive family history (OR: 5.70, 95% CI: 3.41, 9.77; p <0.001), statin use (OR: 2.26, 95% CI: 1.46, 3.52; p <0.001), and longer duration of diabetes (for every year increase OR: 1.19, 95% CI: 1.13, 1.25; p <0.001) Conclusion. The authors conclude that the ASCVD risk score underestimates the ACS risk in subjects with T2DM under medical supervision and may not be different in those who developed and those who did not develop ACS. We also conclude that factors like family history (30% less risk with negative family history), longer duration of diabetes, and higher SBP may be of relevance in those who developed ACS and throw open the need for more objective measures to assess risk in T2DM under medical supervision.