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Diabetic Retinopathy and Cardiovascular Disease


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health prior to having sufficient hyperglycaemia to be diagnosed as having diabetes. Along with treatment inequalities, these physiological differences may also contribute to the observed differences in relative risk of cardiovascular disease between men and women with diabetes. It may also be that the relative effect of diabetes (or any other single cardiovascular risk factor) is greater in low-risk groups than high-risk groups (as noted above), and that this simply reflects that many risk factors have overlapping mechanistic pathways. Thus, adding the first or second risk factor to low-risk groups will have more of an effect than adding the fourth or fifth risk factor to high-risk groups.

      Predicting Risk in Individuals

      Intensive pharmacological risk factor modification for patients with established cardiovascular disease (i.e., “secondary prevention”) is an accepted standard of care with a robust evidence base. Clinical risk assessment and management for patients with diabetes but without known cardiovascular disease is more complicated, with guidelines suggesting various potential approaches. Essentially, the goal is to translate available evidence into day-to-day clinical care, to maximise benefits to individuals, while minimising treatment-related harm and economic costs. Individual patients and healthcare settings will have unique factors that influence treatment decisions that may not always align with published guidelines. Nevertheless, guidelines provide a valuable framework for standardisation of care.

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      An alternate approach is to determine initiation of pharmacotherapy on the basis of an individual’s overall cardiovascular risk. Some guidelines essentially recommend treating all patients with diabetes as being at high risk. For example, the 2013 European Society of Cardiology and European Association for the Study of Diabetes guidelines consider all patients with type 2 diabetes at “high risk” and recommend statin therapy with a target LDL of <2.5 mmol/L (97 mg/dL) [27]. Patients with type 2 diabetes and an additional risk factor are recommended statin therapy with a target LDL of less than 1.8 mmol/L (80 mg/dL). Similarly, the 2018 American Diabetes Association guidelines recommend moderate intensity statin therapy to all patients with diabetes aged 40 years and above [28].

      Cardiovascular Disease Risk Scores

      1. development and internal validation

      2. external validation

      3. model impact studies

      Risk Score Development and Internal Validation

      External Validation