Diabetic retinopathy enhances coronary artery calcium-based cardiovascular risk stratification in patients with type 2 diabetes: insights from the ACCoDiab study.
9 affiliations
- 1Diabetology Department, Sorbonne Université, La Pitié Salpêtrière- Charles Foix University Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
- 2Metabolic Diseases, Diabetes and Comorbidites Research Unit, Institute of Cardiometabolism and Nutrition ICAN, Sorbonne Université, INSERM UMRS1166, Paris, France.
- 3Nutrition and Obesities: Systemic Approaches (NutriOmics) Research Unit, Sorbonne Université, INSERM UMRS1269, Paris, France.
- 4Cardiovascular and Thoracic Imaging Unit, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
- 5Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
- 6Cellular and Systemic Lipid Metabolism in Cardiometabolic Diseases Research Unit, Institute of Cardiometabolism and Nutrition ICAN, INSERM UMRS1166, Sorbonne Université, Paris, France.
- 7Diabetology Department, Sorbonne Université, La Pitié Salpêtrière- Charles Foix University Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France. [email protected].
- 8Metabolic Diseases, Diabetes and Comorbidites Research Unit, Institute of Cardiometabolism and Nutrition ICAN, Sorbonne Université, INSERM UMRS1166, Paris, France. [email protected].
- 9Laboratoire d'Imagerie Biomédicale, Institute of Cardiometabolism and Nutrition ICAN, Sorbonne Université, INSERM, CNRS, Paris, France.
Abstract
Background
The coronary artery calcium (CAC) score is a validated imaging biomarker enhancing cardiovascular risk stratification in patients with type 2 diabetes mellitus (T2DM). However, residual risk persists, particularly among patients with moderate CAC scores. Diabetic retinopathy (DR), a microvascular complication of diabetes, may reflect systemic vascular vulnerability and provide additional prognostic information.Methods
This observational cohort study was conducted as part of the primary prevention ACCoDiab study. 424 patients with T2DM (175 females and 249 males, with a mean age of 61 years) and no history of cardiovascular events underwent CAC scoring and clinical assessments, including DR screening. Patients were monitored for seven years or until the first cardiovascular events, including nonfatal myocardial infarction, ischemic stroke, hospitalization for heart failure, peripheral artery disease revascularization, and cardiovascular death. Cox regression, Kaplan-Meier survival analysis, receiver operating characteristic (ROC) curves, and net reclassification improvement (NRI) were used to evaluate the added prognostic value of DR to CAC scoring and to develop a simple integrated cardiovascular risk score.Results
Fifty patients (11.8%) had incident cardiovascular events. DR was significantly more prevalent among those who experienced events (58% vs. 25%, p < 0.001). Both CAC score and DR were independently associated with cardiovascular events. When incorporating DR into the CAC-based risk model, the predictive power was significantly enhanced AUC 75 [0.69-0.82] vs. 68 [0.61-0.75], p = 0.01). Further improvement was observed after adjusting for traditional risk factors (AUC 79 [0.73-0.86] vs. 73 [0.66-0.81], p = 0.04). The presence of DR reclassified a significant proportion of patients into higher-risk categories, particularly those with low and moderate CAC scores. Additionally, the severity of DR was also found to provide incremental prognostic information but did not provide significant additional stratification beyond the binary presence of DR.Conclusion
The combination of diabetic retinopathy and CAC score significantly enhances cardiovascular risk stratification in T2DM patients, beyond traditional risk factors, highlighting that both microvascular and macrovascular factors should be considered in comprehensive cardiovascular risk assessment. This approach, integrated to clinical routine, may help identify patients for earlier intervention and more personalized treatment strategies. Trial registration NCT03920683.
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BibTeX
@article{phan2026diabetic,
title = {{Diabetic retinopathy enhances coronary artery calcium-based cardiovascular risk stratification in patients with type 2 diabetes: insights from the ACCoDiab study.}},
author = {Franck Phan and Fabrizio Andreelli and Thomas Broussaud and Samia Boussouar and Anne-Caroline Jeannin and Suzanne Laroche and Anne Toulgoat and Antonio Gallo and Olivier Bourron and Alban Redheuil},
journal = {Cardiovascular diabetology},
year = {2026},
month = jul,
doi = {10.1186/s12933-026-03314-w},
url = {https://europepmc.org/article/MED/42907820},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Diabetic retinopathy enhances coronary artery calcium-based cardiovascular risk stratification in patients with type 2 diabetes: insights from the ACCoDiab study.
AU - Franck Phan
AU - Fabrizio Andreelli
AU - Thomas Broussaud
AU - Samia Boussouar
AU - Anne-Caroline Jeannin
AU - Suzanne Laroche
AU - Anne Toulgoat
AU - Antonio Gallo
AU - Olivier Bourron
AU - Alban Redheuil
PY - 2026
DA - 2026/07/01
JO - Cardiovascular diabetology
DO - 10.1186/s12933-026-03314-w
UR - https://europepmc.org/article/MED/42907820
AB - Background The coronary artery calcium (CAC) score is a validated imaging biomarker enhancing cardiovascular risk stratification in patients with type 2 diabetes mellitus (T2DM). However, residual risk persists, particularly among patients with moderate CAC scores. Diabetic retinopathy (DR), a microvascular complication of diabetes, may reflect systemic vascular vulnerability and provide additional prognostic information.Methods This observational cohort study was conducted as part of the primary prevention ACCoDiab study. 424 patients with T2DM (175 females and 249 males, with a mean age of 61 years) and no history of cardiovascular events underwent CAC scoring and clinical assessments, including DR screening. Patients were monitored for seven years or until the first cardiovascular events, including nonfatal myocardial infarction, ischemic stroke, hospitalization for heart failure, peripheral artery disease revascularization, and cardiovascular death. Cox regression, Kaplan-Meier survival analysis, receiver operating characteristic (ROC) curves, and net reclassification improvement (NRI) were used to evaluate the added prognostic value of DR to CAC scoring and to develop a simple integrated cardiovascular risk score.Results Fifty patients (11.8%) had incident cardiovascular events. DR was significantly more prevalent among those who experienced events (58% vs. 25%, p < 0.001). Both CAC score and DR were independently associated with cardiovascular events. When incorporating DR into the CAC-based risk model, the predictive power was significantly enhanced AUC 75 [0.69-0.82] vs. 68 [0.61-0.75], p = 0.01). Further improvement was observed after adjusting for traditional risk factors (AUC 79 [0.73-0.86] vs. 73 [0.66-0.81], p = 0.04). The presence of DR reclassified a significant proportion of patients into higher-risk categories, particularly those with low and moderate CAC scores. Additionally, the severity of DR was also found to provide incremental prognostic information but did not provide significant additional stratification beyond the binary presence of DR.Conclusion The combination of diabetic retinopathy and CAC score significantly enhances cardiovascular risk stratification in T2DM patients, beyond traditional risk factors, highlighting that both microvascular and macrovascular factors should be considered in comprehensive cardiovascular risk assessment. This approach, integrated to clinical routine, may help identify patients for earlier intervention and more personalized treatment strategies. Trial registration NCT03920683.
SN - 1475-2840
ER -