European Journal of Cardiovascular Medicine

Globally, there is a rising incidence of diabetes mellitus. In 1985, 30 million persons worldwide were projected to have diabetes by the World Health Organization. It is estimated that by 2030, this number will have risen to at least 366 million, having reached 217 million in 2005[1]. People with diabetes mellitus are more susceptible to cardiovascular disease (CVD) and mortality than those without the condition, with a two- to four-fold increased risk of cardiovascular death [2]. Diabetes frequently coexists with other cardiovascular risk factors, which in turn accelerate the process of atherogenesis [3-6].
Diabetes mellitus is a chronic metabolic disorder characterized by elevated levels of blood glucose (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both. Insulin, produced by the pancreas, is a hormone that regulates blood sugar by facilitating the uptake of glucose into cells. The clinical features for diabetes were Polyuria, Polydipsia, Polyphagia, Weight loss, Fatigue and Blurred vision. Microvascular complications include Retinopathy, Nephropathy, Neuropathy and macrovascular complications include Cardiovascular Disease, Peripheral Artery Disease (PAD). Lifestyle modifications such as healthy diet by focusing on balanced meals, controlling portion sizes, and monitoring carbohydrate intake; regular exercise as physical activity helps control blood sugar levels and improves overall health and weight management. Diabetes is a major risk factor for cardiovascular diseases (CVD). Individuals with diabetes have a higher likelihood of developing heart disease and stroke. Diabetes often coexists with high blood pressure (hypertension) and abnormal lipid profiles, further increasing the risk of CVD. Diabetes contributes to chronic inflammation and accelerates the formation of atherosclerotic plaques, narrowing blood vessels. Close monitoring of blood pressure, cholesterol levels, and blood glucose is crucial to managing cardiovascular risk. Lifestyle modifications and medications may be prescribed to reduce cardiovascular risk in individuals with diabetes.

Over the years, several risk scores have been created; however, only a small number of them have been especially designed with the diabetes community in mind. Twelve out of forty-five prediction models in a systematic assessment of models for predicting the risk of CVD in people with type 2 diabetes were created especially for these patients [7]. Most of them predicted the 5-year risk of either total or coronary heart disease (CHD), and the most often used predictors were age, sex, length of diabetes diagnosis, HbA1c (glycosylated haemoglobin A1c), and smoking. These models typically do not include non-traditional risk variables, like low birth weight and new biomarkers, which may have dubious clinical significance [8, 9]. Diabetes was one of several risk factors included in prediction models drawn from the general population, along with age, sex, systolic blood pressure, smoking, and cholesterol. Merely 33% of the risk scores have undergone external validation in a diabetic group [7].
The investigation involves the use of PROCAM Score in predicting cardiovascular events in T2DM patients. The PROCAM Score, which incorporates traditional risk factors such as age, gender, lipid profile, blood pressure, and smoking status, will be scrutinized for its applicability and predictive precision within this specific diabetic population.
The findings of this study aim to provide valuable insights into the utility of the PROCAM Score as a cardiovascular risk assessment tool specifically tailored for individuals with Type 2 diabetes. The implications of such assessments could contribute to more targeted and effective preventive strategies, ultimately reducing the burden of cardiovascular complications in this high-risk diabetic population

1. Study Design:
• Adopted a prospective cohort study design to assess cardiovascular risk in Type 2 diabetes.
• A diverse population of individuals with Type 2 diabetes from outpatient clinics or diabetes management programs was recruited.
2. Participant Selection:
Inclusion criteria:
• Individuals aged 20 to > 60 years diagnosed with Type 2 diabetes.
• Willingness to participate in the study by providing signed informed consent form
• Patients who have diagnosed T2DM according to ADA guidelines
• Patients taking anti-diabetic medicine.
Exclusion Criteria:
• Patients who had a history of cardiovascular illnesses, such as angina, heart attacks, strokes, or transient ischemic attacks.
• Patients suffering with HIV, cancer, asthma, hepatic disease, and other infectious chronic disorders
• Pregnant women, breastfeeding, or taking contraceptive pills
• Patients who show non-compliance with medications
• Drop out cases during the study
• Patients taking medications that could affect their inflammatory status
• Patient having any form of cognitive impairment
• Patients having audio-visual impairment.
• Patients with incomplete interview were also excluded.
3. Ethical Approval:
• Ethical approval from relevant institutional review boards was obtained.
• Ensured informed consent from all participants.
4. CVD risk prediction:
• Utilized the Prospective Cardiovascular Münster (PROCAM) Risk Score calculator.
• Included parameters such as age, gender, total cholesterol, HDL cholesterol, systolic blood pressure, smoking status, and family history of premature coronary heart disease.
Established in 1978, the Prospective Cardiovascular Münster (PROCAM) study aimed to explore the epidemiology of coronary heart disease (CHD), developed in Northern Europe. Through the analysis of outcome data from a 10-year follow-up, a risk score for coronary events was developed, which included LDL cholesterol, HDL cholesterol,

systolic blood pressure, smoking, triglycerides, diabetes, family history of cardiovascular disease, sudden death and both fatal and non-fatal MI. Of great significance is the realization that the majority of these characteristics also represent components of the metabolic syndrome; low levels of HDL cholesterol and elevated triglycerides, the main ingredients of atherogenic dyslipidemia, which is frequently observed in patients with diabetes and/or metabolic syndrome, were identified as independent variables influencing coronary events. It takes into account various risk factors to assess the likelihood of a cardiovascular event. It may be noted that specific PROCAM score tables may vary, and it's crucial to use the version validated and recommended by healthcare professionals.
The risk factors considered in the PROCAM score:
1. Age
2. Gender
3. Total cholesterol
4. HDL cholesterol
5. Smoking status
6. Blood pressure
7. Family history of premature myocardial infarction (heart attack)
The actual PROCAM score calculation involves assigning points based on these factors and summing them to determine the overall risk. The risk is then categorized into different levels (e.g., low, moderate, high) (Table 1) [10].

In order to compare the levels of several risk factors in T2DM patients without CVD/stroke to those in T2DM patients with CVD/stroke and healthy individuals, the current study was carried out. Additionally, the study aimed to investigate the potential function of biomarkers in the primary prevention of CVDs and stroke.

The current study used the PROCAM score to examine the 10-year predicted cardiovascular risk and potential factors among individuals with diabetes mellitus. The purpose of this study was to evaluate the cardiovascular risk in patients with diabetes who were visiting a medical college hospital. Several common scoring systems are available for evaluating risk; PROCAM scoring was employed in this investigation. Study participants who were known to have diabetes were divided into three risk categories based on their scoring: low, middle, and high. According to this study, around 31% of participants have a high risk of cardiovascular problems. The results align with the research conducted by Marreswaran et al., [10] wherein 29.5% of study participants were at higher risk of CVD.

In 121 cities across 27 Indian states, a comparable multi-centric study [12] on newly diagnosed type 2 diabetes revealed a 7% greater risk of cardiovascular disease (CVD) among smokers and a 5% higher risk among hypertensive based on PROCAM scores. This is comparable to our present study indicating greater risk for smokers.  According to this study, women are more likely to experience cardiovascular problems.  It agrees with the results of the research conducted by Leon, Maddox, and Möller-Leimkühler [13, 14]. According to the previous study, women are three to five times more likely than men to acquire cardiovascular disease.

A study by Assmann G et al., [15] only five variables – age, sex, smoking, diabetes and systolic blood pressure – were included in the PROCAM cerebral ischemic risk score. This is consistent with data from the Atherosclerosis Risk in Communities study, which showed that the presence of elevated blood pressure and/or elevated fasting glucose were key components of the metabolic syndrome associated with increased risk of stroke.

Nearly half of the individuals in the current study (31%) had a high risk of hypertension; this is comparable to some studies that found that 60% of diabetics had hypertension. In another multi-center investigation [16], 42% of those with confirmed diabetes were found to have hypertension. The present study's findings are in line with previous research conducted by Corsi and Subramanian, indicating that individuals from higher socioeconomic classes which include smoking in India seem to have a higher likelihood of developing type 2 diabetes [17].

17.5% of all individuals used tobacco products, with a larger percentage among men. One of the main risk factors for CVD and the start of DM in this population is tobacco smoking. Smoking is taken into account as a significant factor in the PROCAM scores assessment. The Indian populace uses more chewing and smokeless tobacco than people in developed nations [18].   Research has demonstrated that smokeless tobacco is one of the factors contributing to insulin resistance and has higher nicotine content than cigarettes [19-22]. The public needs to be made aware of the dangers of consuming smokeless tobacco.  According to this study, 54 % of participants are at high and intermediate risk of acquiring cardiovascular disease. This finding is consistent with a study by Garg et al. that found 51.9% of participants were at high risk of having the same condition using the Framingham risk score [23].

The evaluation of cardiovascular risk in patients with Type 2 Diabetes Mellitus (T2DM) is pivotal in addressing the heightened susceptibility to cardiovascular complications in this population. This study delved into multifaceted aspects, revealing a comprehensive landscape of factors contributing to increased cardiovascular risk in individuals with Type 2 diabetes. The research unequivocally demonstrated that individuals with Type 2 diabetes face a significantly elevated risk of cardiovascular events. Traditional risk factors, including age, gender, dyslipidemia, and hypertension, were identified as major contributors. The heightened cardiovascular risk observed in Type 2 diabetes patients necessitates a comprehensive and evolving approach to patient care. By unraveling the complexity of risk factors and acknowledging the dynamic nature of diabetes-related contributors, this study contributes to the evolving landscape of cardiovascular risk management in this high-risk population. Continued research and implementation of targeted interventions are essential for reducing the burden of cardiovascular morbidity and mortality in individuals with Type 2 diabetes.Top of Form

Ethical Clearance : Ethical clearance was obtained from the institutional ethical committee prior to commencement of study.

Conflict of Interest : Nil

Source of Funding : Self

1. Rathmann W, Giani G. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004; 27:2568–2569.
2. Gu K, Cowie CC, Harris MI. Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971-1993. Diabetes Care. 1998; 21:1138–1145.
3. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care. 1993;16: 434–444. 
4. Turner RC, Millns H, Neil HA, Stratton IM, Manley SE, Matthews DR, Holman RR. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23) BMJ. 1998;316:823–828. 
5. Fuller JH, Stevens LK, Wang SL. Risk factors for cardiovascular mortality and morbidity: the WHO Mutinational Study of Vascular Disease in Diabetes. Diabetologia. 2001; 44 Suppl 2:S54–S64. 
6. Kuusisto J, Mykkänen L, Pyörälä K, Laakso M. NIDDM and its metabolic control predict coronary heart disease in elderly subjects. Diabetes. 1994;43:960–967. 
7. van Dieren S, Beulens JW, Kengne AP, Peelen LM, Rutten GE, Woodward M, van der Schouw YT, Moons KG. Prediction models for the risk of cardiovascular disease in patients with type 2 diabetes: a systematic review. 2012;98:360–369. 
8. Wang TJ. New cardiovascular risk factors exist, but are they clinically useful? Eur Heart J. 2008;29:441–444.
9. Visentin S, Grumolato F, Nardelli GB, Di Camillo B, Grisan E, Cosmi E. Early origins of adult disease: low birth weight and vascular remodeling. 2014; 237:391–399. 
10. Mareeswaran N., R. Umadevi, A. K. Savitha. Assessment of cardiovascular risk among diabetic patients in an urban area of Kancheepuram district, India: a cross sectional study.  Int J Community Med Public Health. 2018; 5(9):4098-4102.
11. Assmann G, Cullen P, Schulte H. Simple scoring scheme for calculating the risk of acute coronary events based on the 10-year follow-up of the prospective cardiovascular Münster (PROCAM) study. Circulation. 2002 Jan 22;105(3):310-5. doi: 10.1161/hc0302.102575. Erratum in: Circulation 2002 Feb 19;105(7):900.
12. Unnikrishnan AG, Sahay RK, Phadke U, et al.: Cardiovascular risk in newly diagnosed type 2 diabetes patients in India. PLoS One. 2022, 17:e0263619. 10.1371/journal.pone.0263619.
13. Leon BM, Maddox TM. Diabetes and cardiovascular disease: Epidemiology, biological mechanisms, treatment recommendations and future research. World J Diabetes. 2015; 6(13):1246.
14. Möller-Leimkühler AM. Gender differences in cardiovascular disease and comorbid depression. Dialogues Clin Neurosci. 2007;9(1):71.
15. Assmann G, Cullen P, Schulte H. Simple scoring scheme for calculating the risk of acute coronary events based on the 10-year follow-up of the Prospective Cardiovascular Munster (PROCAM) study. Circulation 2002; 105:310-5.
16. Corsi DJ, Subramanian SV. Association between socioeconomic status and self-reported diabetes in India: a cross-sectional multilevel analysis. BMJ open. 2012 Jan 1; 2(4):e000895.
17. Unnikrishnan AG, Sahay RK, Phadke U, et al.: Cardiovascular risk in newly diagnosed type 2 diabetes patients in India. PLoS One. 2022, 17:e0263619. 1371/journal.pone.0263619
18. Spatial, temporal, and demographic patterns in prevalence of chewing tobacco use in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet Public Health. 2021, 6:e482-99. 1016/S2468-2667(21)00065-7
19. Stepanov I, Gupta PC, Dhumal G, Yershova K, Toscano W, Hatsukami D, Parascandola M: High levels of tobacco-specific N-nitrosamines and nicotine in Chaini Khaini, a product marketed as snus. Tob Control. 2015, 24:e271-4. 1136/tobaccocontrol-2014-051744
20. Sharma P, Murthy P, Shivhare P: Nicotine quantity and packaging disclosure in smoked and smokeless tobacco products in India. Indian J Pharmacol. 2015, 47:440-3. 4103/0253-7613.161273
21. Bajaj M: Nicotine and insulin resistance: when the smoke clears. Diabetes. 2012, 61:3078-80. 2337/db12-1100
22. Bergman BC, Perreault L, Hunerdosse D, Kerege A, Playdon M, Samek AM, Eckel RH: Novel and reversible mechanisms of smoking-induced insulin resistance in humans. Diabetes. 2012, 61:3156-66. 2337/db12-0418.
23. Garg N, Muduli SK, Kapoor A, Tewari S, Kumar S, Khanna R, et al. Comparison of different cardiovascular risk score calculators for cardiovascular risk prediction and guideline recommended statin uses. Indian Heart J. 2017; 69(4):458-63.

A total of 200 patients were considered for this study. Of these, more than half (57 %) patients were female and 43 % patients were male.

Nearly half of the patients (46 %) considered for this study had low cardiovascular risk. Of this majority of them (19 %) were in the PROCAM score categories 4, while 14.5 % patients belonged to category 3, 6.5 % patients were in category 2 and only 6 % patients were in category 1. Nearly one-fourth (23 %) patients fell into the PROCAM score category 5 having intermediate cardiovascular risk. Nearly one-third (31 %) patients had a high cardiovascular risk with 17.5% patients in PROCAM score category 6 and 13.5 % patients in category 7.