Monitoring, early intervention crucial for preventing CVD in type 1 diabetes
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People with type 1 diabetes have an increased risk for cardiovascular disease and providers should use a multifaceted approach to reduce CVD risk, according to a presenter at the Cardiometabolic Health Congress.
“The importance of managing CVD and CVD risk in patients with type 1 diabetes is a real component of comprehensive diabetes care,” Bernard Zinman, OC, MDCM, FRCP, FACP, senior scientist at Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, and professor of medicine at the University of Toronto, said during a presentation. “We need to think about CV risk in type 1 diabetes over the entire lifespan of these patients, from childhood to the elderly.”
While the prevalence of CVD in people with diabetes is higher than people without diabetes, Zinman noted people with type 1 diabetes are especially at risk. Data published in Diabetes Care in 2014 showed men with type 1 diabetes had a four times higher risk for coronary heart disease than age-matched controls, and women had an eight times higher risk. For type 2 diabetes, the risk for CHD was two times higher in men and four times higher in women than age-matched controls.
Risk factors for CVD
There are many factors contributing to CVD in type 1 diabetes, including cardiac autonomic neuropathy, diabetic neuropathy, chronic hyperglycemia, hypoglycemia, insulin resistance in those with overweight and obesity, glycemic variability and typical CV risk factors such as smoking and hypertension.
Data from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study (DCCT/EDIC) showed treatment for CVD prevention can reduce prevalence. Study participants receiving intensive therapy had a 42% lower risk for any first CV event compared with those receiving conventional therapy at 21 years (P = .016). The risk for non-fatal MI, stroke or CVD mortality was 57% lower with intensive therapy compared with conventional therapy (P = .018).
“Even with this small number of events, we’re able to show a very robust effect of intensive therapy on CV outcomes,” Zinman said.
Cardiovascular autonomic neuropathy is another risk factor for CVD in type 1 diabetes. In the DCCT/EDIC cohort, those with cardiovascular autonomic neuropathy have a higher risk for first CVD event compared with people with no cardiovascular autonomic neuropathy (HR = 2.79; 95% CI, 1.91-4.99; P < .001).
There are also genetic risk factors that can increase CVD risk in type 1 diabetes. In a study published in Diabetes Care, people in DCCT/EDIC with highest polygenic risk score had significantly higher incidences of CVD than those with lower scores.
CVD prevention in type 1 diabetes
The American Diabetes Association’s 2021 Standards of Medical Care in Diabetes details steps providers can take to help prevent CVD in type 1 diabetes.
For people with type 1 diabetes and hypertension, using combination therapy is highly recommended, Zinman said. People with an initial BP of greater than 160 mm Hg systolic/100 mm Hg diastolic should receive two agents, while those with a BP between 140/90 mm Hg and 160/100 mm/Hg should start with one agent. Changes in diet and increased physical activity are lifestyle changes people can take the reduce CVD risk.
For adults aged younger than 40 years not taking statins or other lipid-lowering therapy, a lipid profile should be obtained at diabetes diagnosis and every 5 years thereafter. For those starting a statin or lipid-lowering therapy, a lipid profile should be obtained at initiation, 4 to 12 weeks after initiation, and then annually.
Statin therapy for primary CVD prevention will vary based on a person’s age and CVD history. People with diabetes aged 40 to 75 years with atherosclerotic CVD should be prescribed moderate-intensity statin therapy alongside lifestyle intervention. Those aged 20 to 39 with ASCVD risk factors can also be started on statin therapy with lifestyle therapy. People with type 1 diabetes and multiple ASCVD risk factors or aged 50 to 70 years may benefit from high-intensity statin therapy, and those with a 10-year ASCVD risk of 20% or higher could have ezetimibe added to maximally tolerated statin therapy.
For people with type 1 diabetes and ASCVD, a high-intensity statin should be added to lifestyle therapy, regardless of age, and those who are very high risk could receive an additional therapy to lower LDL cholesterol. Smoking cessation is also critical for people of any age with type 1 diabetes, he said.
Zinman said more research is needed on a couple of other possible therapy options for CVD risk reduction in type 1 diabetes.
“There’s now a lot of debate with SGLT2 inhibitors in type 1 diabetes,” Zinman said. “We know that these drugs are very effective in the context of heart failure in type 2 diabetes. There are lots of type 1’s who develop heart failure. Should they be treated with a SGLT2 inhibitor? It is not approved in the United States or Canada, but it is in Europe. The problem is diabetic ketoacidosis risk, can we mitigate that?”
Additionally, GLP-1 receptor agonists could have a role in lowering CVD risk in type 1 diabetes, especially for those who have gained weight. Zinman said data has shown GLP-1 receptors can modestly reduce HbA1c but are also associated with increases in hypoglycemia.
References:
- ADA Standards of Medical Care in Diabetes — 2021. Available at: https://care.diabetesjournals.org/content/44/Supplement_1. Accessed: Oct. 17, 2021.
- Bebu I, et al. Diabetes Care. 2021;doi:10.2337/dc20-2388.
- DCCT/EDIC Study Research Group. N Engl J Med. 2005;doi:10.1056/NEJMoa052187.
- Harding JL, et al. Diabetes Care. 2014;doi:10.2337/dc14-0096.
- Pop-Busui R, et al. Diabetes Care. 2017;doi:10.2337/dc16-1397.
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Zinman B. Session III: Diabetes. Presented at: Cardiometabolic Health Congress; Oct. 14-17, 2021; National Harbor, Md. (hybrid meeting).
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