Comparison of prediction models for cardiovascular and mortality risk in people with type 2 diabetes: An external validation in 23 685 adults included in the UK Biobank

Abstract

<h3>Aims</h3><p>To validate cardiovascular risk prediction models for individuals with diabetes using the UK Biobank in order to assess their applicability.</p><h3>Methods</h3><p>We externally validated 19 cardiovascular risk scores from seven risk prediction models (Chang et al., Framingham, University of Hong Kong-Singapore [HKU-SG], Li et al, RECODe [risk equations for complications of type 2 diabetes], SCORE [Systematic Coronary Risk Evaluation] and the UK Prospective Diabetes Study Outcomes Model 2 [UKPDS OM2]), identified from systematic reviews, using UK Biobank data from 2006 to 2021 (<em>n</em> = 23 685; participant age 40–71 years, 63.5% male). We evaluated performance by assessing the discrimination and calibration of the models for the endpoints of mortality, cardiovascular mortality, congestive heart failure, myocardial infarction, stroke, and ischaemic heart disease.</p><h3>Results</h3><p>Over a total of 269 430 person-years of follow-up (median 11.89 years), the models showed low-to-moderate discrimination performance on external validation (concordance indices [c-indices] 0.50–0.71). Most models had low calibration with overprediction of the observed risk. RECODe outperformed other models across four comparable endpoints for discrimination: all-cause mortality (c-index 0.67, 95% confidence interval [CI] 0.65–0.69), congestive heart failure (c-index 0.71, 95% CI 0.69–0.72), myocardial infarction (c-index 0.67, 95% CI 0.65–0.68); and stroke (c-index 0.65, 95% CI 0.62–0.68), and for calibration (except for all-cause mortality). The UKPDS OM2 had comparable performance to RECODe for all-cause mortality (c-index 0.67, 95% CI 0.66–0.69) and cardiovascular mortality (c-index 0.71, 95% CI 0.70–0.73), but worse performance for other outcomes. The models performed better for younger participants and somewhat better for non-White ethnicities. Models developed from non-Western datasets showed worse performance in our UK-based validation set.</p><h3>Conclusions</h3><p>The RECODe model led to better risk estimations in this predominantly White European population. Further validation is needed in non-Western populations to assess generalizability to other populations.</p>