2014 AHA/ADA Scientific Statement on Type 1 Diabetes Mellitus and Cardiovascular Disease

BySteven Lome, MD

Year Released: 2014

Societies: American Heart Association (AHA), American Diabetes Association (ADA)

Summary:

The pathophysiology underlying the relationship between cardiovascular (CV) events, cardiovascular disease (CVD) risk factors and type 1 diabetes is not well-understood, according to a statement from the AHA and ADA on type 1 diabetes and CVD.

Management approaches to reducing CVD have been deduced in large part from experiences with type 2 diabetes, despite the longer duration of disease in type 1 diabetes and the differences in the underlying pathophysiology, according to the document.

Findings from the Diabetes Control and Complications Trial (DCCT), which compared intensive glycemic control with usual care, and its follow-up study, Epidemiology of Diabetes Interventions and Complications (EDIC), led to intensive management of diabetes becoming the standard of care and has led to increasing longevity.

However, the panel wrote, physicians’ understanding of CVD in type 1 diabetes comes mostly from the previous era of less intensive glycemic control.

The statement summarizes evidence-based observations of potential differences in the pathophysiology of type 1 diabetes compared with type 2 diabetes and attempts to explore the implications of the concepts for treatment of CV risk factors in patients with type 1 diabetes.

Cardiovascular risk factors, modifiers in type 1 diabetes

CVD risk brought on by unhealthy behaviors and associated CVD risk factors requires careful consideration, according to the statement. The authors recommend the avoidance of smoking, maintenance of a normal weight, and consumption of a balanced diet replete in fruits and vegetables, low in saturated fat and sodium, and enriched in whole grains.

The panel wrote that it is important for physicians to recommend lifestyle changes to minimize excessive weight gain in type 1 diabetes, including caloric restriction when indicated and increased physical activity.

The authors also wrote that the recommendations must be accompanied by appropriate patient education about frequent blood glucose monitoring along with appropriate modifications in bolus or basal insulin administration with food intake and exercise to minimize the risk for hypoglycemia.

Dyslipidemia

Similar to the general population, most studies indicate that dyslipidemia is a risk factor for CVD in patients with type 1 diabetes, according to the statement, and pharmacotherapy is generally used more aggressively in patients with type 1 diabetes and lipid disorders than in those without diabetes.

However, as noted in the statement, recommendations for treatment are mostly influenced by interventional trials in adults with type 2 diabetes, in which rates of CVD events are equivalent to those in secondary prevention populations. It is unclear whether this is appropriate for type 1 diabetes, although epidemiological evidence from the EDIC study suggests that a low-density lipoprotein (LDL) level greater than 100 mg/dL is associated with increased CVD risk, and a meta-analysis of LDL lowering that included patients with type 1 diabetes suggests that LDL lowering reduces CV events.

Adults with type 1 diabetes who have abnormal lipids and additional risk factors for CVD, such as hypertension, obesity or smoking, who have not developed CVD should be treated with statins, according to the statement.

Additionally, the panel wrote that adults with CVD and type 1 diabetes should also be treated with statins, regardless of whether they have additional risk factors.