AHA and ADA: CV risk assessment, monitoring essential for patients with type 1 diabetes

A greater understanding of the pathophysiology, risk prediction and treatment of CVD in patients with type 1 diabetes is essential to minimize the impact of these interrelated conditions, according to a new scientific statement from the American Heart Association and American Diabetes Association.

“CVD is a long-term complication of type 1 diabetes that is a major concern for patients and health care providers. … Despite the known higher risk of CVD in individuals with type 1 diabetes mellitus, the pathophysiology underlying the relationship between CV events, CVD risk factors and type 1 diabetes is not well understood,” the authors wrote in Diabetes Care.

The statement reviews the current knowledge about the relationship between type 1 diabetes and CVDs including CHD, cerebrovascular disease and peripheral artery disease. It clarifies the definition of type 1 diabetes, discusses the latest approaches to monitoring, diagnosis and treatment, provides in-depth epidemiological data, and more.

Risk factors

Risk factors important to CVD in patients with type 1 diabetes that could be important potential targets for risk reduction include:

Hypertension.
Proteinuria.
Obesity.
HbA1c.
Lipid levels.
Age.
Diabetes duration.
Unhealthy behaviors, including diet, exercise and smoking status.

Pediatric patients should receive particular attention, as “CVD risk factors are more common in children with type 1 diabetes than in the general pediatric population,” according to the statement.

“More aggressive management of CVD risk factors and of the disease itself is likely to have a positive effect on CVD event rates,” the authors wrote.

Monitoring and screening

Risk-prediction algorithms for CVD are not widely used for patients with type 1 diabetes. Approaches to the assessment of CVD burden in this patient population may include applying the same CHD risk-assessment and diagnostic strategies as are used in the general population, according to the statement.

While routine stress testing is not recommended for patients with type 1 diabetes, additional testing is recommended for any patient with symptoms suggestive of CHD. Further, advanced testing may be useful in patients with type 1 diabetes, according to the statement. Although data are lacking, a coronary artery calcium (CAC) assessment for risk prediction in patients with type 1 diabetes may be helpful. “It is reasonable to apply the current guidelines for the use of CAC assessment in type 1 diabetes, as recommended for the general population,” the authors wrote.

Other testing modalities for CVD may be less useful, such as the evaluation of endothelial dysfunction by flow-mediated dilation and/or brachial artery reactivity or cardiac magnetic resonance imaging.

The following screening schedules for CVD risk factors are recommended for patients with type 1 diabetes: hyperglycemia (HbA1c, glucose monitoring), every 3 months; diabetic kidney disease (urine albumin to creatinine ratio, estimated glomerular filtration rate), annually, starting at 5 years after diagnosis; dyslipidemia (fasting lipid profile), every 2 years for adults and every 3 to 5 years for children aged 10 to 21 years; hypertension, each visit; prehypertension, each visit.

Opportunities remain

The authors also address areas in which the understanding of CVD in patients with type 1 diabetes is lacking. However, they acknowledge that “many of these data may be historical and that better glycemic control is changing the landscape of atherosclerosis in type 1 diabetes.”

Specific areas worthy of attention include the understanding of cellular and molecular pathophysiology in CVD and type 1 diabetes; the development of atherosclerotic lesions and the natural history; the role of inflammatory markers; tests for preclinical disease; novel biomarkers; safe and effective pharmacological approaches; the best lifestyle modifications.

“Much work remains to be done to improve our understanding of type 1 diabetes and to help ameliorate the CVD effects of this important disease,” the authors wrote.

For more information:

deFerranti SD. Diabetes Care. 2014;doi:10.2337/dc14-172.

Disclosure: See the full statement for a full list of the authors’ relevant financial disclosures.