Precision Prognostics for Cardiovascular Disease in Type 2 Diabetes: A Systematic Review and Meta-analysis
Authors: Ahmad Abrar , Lim Lee-Ling , Morieri Mario Luca , Tam Claudia Ha-ting , Cheng Feifei , Chikowore Tinashe , Dudenhöffer-Pfeifer Monika , Fitipaldi Hugo , Huang Chuiguo , Kanbour Sarah , Sarkar Sudipa , Koivula Robert Wilhelm , Motala Ayesha A. , Tye Sok Cin , Yu Gechang , Zhang Yingchai , Provenzano Michele , Sherifali Diana , de Souza Russell J. , Tobias Deirdre Kay ,   ADA/EASD PMDI, Gomez Maria F. , Ma Ronald C.W. , Mathioudakis Nestoras 
Published: April 2023

Background

Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with type 2 diabetes (T2D).

Methods

We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies.

Results

Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded thehighest predictive utilityfor N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence);moderate predictive utilityfor coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); andlow predictive utilityfor C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort.

Conclusions

Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Plain Language Summary

Patients with T2D are at high risk for CVD but predicting who will experience a cardiac event is challenging. Current risk tools and prognostic factors, such as laboratory tests, may not accurately predict risk in all patient populations. There is a need for personalized risk prediction tools to classify patients more accurately so that CVD prevention can be targeted to those who need it most. This study summarizes the best available evidence for novel biomarkers, genetic markers, and risk scores that predict CVD in individuals with T2D. We found that four laboratory markers and a genetic risk score for CHD had high predictive utility beyond traditional CVD risk factors. Risk scores had modest predictive utility when tested in diverse populations. More studies are needed to determine their usefulness in clinical practice. The highest strength of evidence was observed for NT-proBNP, a biomarker currently measured to monitor patients with heart failure in clinical practice, but not for CVD prediction in T2D.