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Estimating individual lifetime risk of incident cardiovascular events in adults with type 2 diabetes: an update and geographical calibration of the DIAbetes Lifetime perspective model (DIAL2).

BACKGROUND
The 2021 ESC cardiovascular disease (CVD) prevention guidelines recommend the use of (lifetime) risk prediction models to aid decisions regarding intensified preventive treatment options in adults with type 2 diabetes, e.g. the DIAbetes Lifetime perspective model (DIAL model). The aim of this study was to update the DIAL-model using contemporary and representative registry data (DIAL2) and to systematically calibrate the model for use in other European countries.


METHODS AND RESULTS
The DIAL2 model was derived in 467,856 people with type 2 diabetes without a history of CVD from the Swedish National Diabetes Register, with a median follow-up of 7.3 years (IQR 4.0-10.6 years) and comprising 63,824 CVD (including fatal CVD, nonfatal stroke and nonfatal myocardial infarction) events and 66,048 non-CVD mortality events. The model was systematically recalibrated to Europe's low and moderate risk region using contemporary incidence data and mean risk factor distributions. The recalibrated DIAL2 model was externally validated in 218,267 individuals with type 2 diabetes from the Scottish Care Information - Diabetes (SCID) and Clinical Practice Research Datalink (CPRD). In these individuals, 43,074 CVD events and 27,115 non-CVD fatal events were observed. The DIAL2 model discriminated well, with C-indices of 0.732 (95%CI 0.726-0.739) in CPRD and 0.700 (95%CI 0.691-0.709) in SCID.


INTERPRETATION
The recalibrated DIAL2 model provides a useful tool for the prediction of CVD-free life expectancy and lifetime CVD risk for people with type 2 diabetes without previous CVD in the European low and moderate risk regions. These long-term individualized measures of CVD risk are well suited for shared decision making in clinical practice as recommended by the 2021 CVD ESC prevention guidelines.