Multimarker Assessment of Cardiovascular Risk in Type 2 Diabetes: Role of Inflammation, Myocardial Injury, and Glycaemic Control
Abstract
Background: Diabetes mellitus, particularly Type 2 Diabetes (T2DM), has become a major public health concern globally, especially in low- and middle-income countries like India. The prevalence of T2DM in India is rising, with Punjab showing particularly high rates due to dietary patterns, sedentary lifestyles, and genetic predisposition. T2DM is strongly linked to Cardiovascular Disease (CVD), and inflammatory markers such as high-sensitivity C-Reactive Protein (hs-CRP), fibrinogen, and Hemoglobin A1c (HbA1c) may be associated with higher cardiovascular risk in diabetic patients. This study aims to evaluate the role of hs-CRP, fibrinogen, HbA1c, and other biomarkers in assessing cardiovascular risk in patients with T2DM in Punjab, North India, and to examine whether these biomarkers show additional associations with higher cardiovascular risk strata beyond traditional markers like Low-Density Lipoprotein Cholesterol (LDL-C).
Methods: A cross-sectional observational study was conducted from January 2024 to June 2025, involving 1,200 patients diagnosed with T2DM from both urban and rural areas of Punjab. Participants aged 30–70 years were selected using stratified random sampling. Data collection included demographic, clinical, and biochemical information. Fasting blood samples were analyzed for hs-CRP, fibrinogen, HbA1c, LDL-C, and other biomarkers. Cardiovascular risk was assessed using the Framingham Risk Score (FRS), which, in this South Asian diabetic cohort, was applied as a comparative risk stratification tool rather than as a fully validated prognostic model. Multivariable logistic regression and Receiver Operating Characteristic (ROC) curve analysis were used to assess associations between biomarkers and higher cardiovascular risk categories and the presence of CVD.
Results: The study found significant differences in biomarker levels between urban and rural populations, with rural participants showing higher levels of hs-CRP, fibrinogen, HbA1c, LDL-C, and other markers of myocardial injury, including troponins and B-type Natriuretic Peptide (BNP). Elevated hs-CRP (>3 mg/L), fibrinogen (>400 mg/dL), and HbA1c (>9%) were associated with higher FRS-defined cardiovascular risk categories and with CVD presence, and logistic regression identified hs-CRP and LDL-C as independently associated with CVD after adjustment for conventional risk factors. Biomarkers such as High-Sensitive Troponin I (hs-TnI) and Lipoprotein-associated Phospholipase A2 (Lp-PLA2) were also strongly associated with prevalent CVD.
Conclusions: This cross-sectional study highlights that inflammatory and cardiac biomarkers are strongly associated with higher cardiovascular risk strata and prevalent CVD in T2DM patients, particularly in rural populations where biomarker levels and calculated risk scores are higher. The findings support the potential role of these biomarkers in multimarker risk stratification in diabetic populations, especially in resource-limited settings, while underscoring that longitudinal studies are required before inferring prognostic or predictive value or implementing biomarker-guided interventions.
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