Cardiovascular disease risk estimates for primary prevention in the US prediabetes and diabetes population using the...

Cardiovascular disease (CVD) risk assessment is essential for guiding preventive strategies in populations with diabetes and prediabetes. The American Heart Association's Predicting Risk of CVD Events (PREVENT) equations, introduced in 2023, were developed to address limitations of previous risk assessment tools, including the 2013 Pooled Cohort Equations (PCEs). We compared cardiovascular risk estimates and subsequent statin eligibility using these equations in US adults with prediabetes and diabetes.

Using nationally representative data from the National Health and Nutrition Examination Survey (NHANES) 2013-2020, we analysed 8693 participants aged 40-75 years without known CVD, representing ~104 million US adults. We estimated the 10-year risk of atherosclerotic CVD (ASCVD), heart failure (HF), and CVD using the PREVENT equations and PCEs, and assessed statin eligibility based on the 2019 American College of Cardiology/American Heart Association and 2024 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.

The PREVENT equations consistently estimated lower 10-year ASCVD risk compared with PCEs across all groups. In the diabetes population, 10-year ASCVD risk was 8.0% (95% CI, 7.7-8.4) using the full PREVENT equation versus 15.7% (95% CI, 14.9-16.4) using PCEs. Similarly, in prediabetes, the risk was 4.0% (95% CI, 3.7-4.2) versus 7.5% (95% CI, 6.8-8.2). HF risk was particularly elevated in diabetes (9.9%, 95% CI, 9.3-10.4) compared with prediabetes (3.7%, 95% CI, 3.4-4.0) and no diabetes/prediabetes (2.8%, 95% CI, 2.7-3.0). When applying 2024 KDIGO guidelines, statin eligibility decreased from 81.6% to 56.5% in diabetes and from 32.5% to 11.8% in prediabetes when using PREVENT versus PCEs. Less than half of statin-eligible individuals were receiving treatment.

The PREVENT equations estimate substantially lower ASCVD risk compared with PCEs in diabetes and prediabetes populations. These differences substantially impact statin eligibility under current guidelines. The PREVENT equations offer a more comprehensive framework that may better reflect contemporary risk profiles, potentially improving targeted preventive strategies in these high-risk populations.