Diabetes may be ‘no longer equivalent to CVD’ as a CV risk factor
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Adults with diabetes in Ontario, Canada, had a greater reduction in risk for cardiovascular events from 1994 to 2014 compared with adults with prior CV disease, according to a research letter published in JAMA.
In findings from a retrospective population-based cohort study, the risk for CV events among adults with diabetes, prior CVD or both diabetes and prior CVD was greater compared with adults with neither condition in both 1994 and 2014. However, the rate of CV events declined for all adults during that period, and those with diabetes had the largest decline in event rate.
“Twenty-five years ago, diabetes was first described as a ‘CV risk equivalent,’” Calvin Ke, MD, PhD, assistant professor in the department of medicine at the University of Toronto, told Healio. “This term means that people with diabetes had a similar risk of a CV event as those with prior CVD. We looked at 25 years of data from Ontario, Canada. In 1994, people with diabetes had double the risk of CV events compared to people without diabetes or prior CVD. This doubling in risk was similar to people with prior CVD. By 2014, people with diabetes had a 58% increase in CV risk, while people with prior CVD disease still had around double the CV risk compared to disease-free individuals. This evidence suggests that modern approaches have had a major impact on reducing CV complications in diabetes. Still, diabetes remains a strong CV risk factor.”
Diabetes and CVD increase risk for CV events
Ke and colleagues conducted an analysis of administrative health care data from Ontario, Canada, of adults aged 20 to 84 years. Data were extracted for adults alive in each of the following years: 1994, 1999, 2004, 2009 and 2014. Researchers selected a sample of 25% of eligible adults for each index year and followed them for up to 5 years. Within each year, adults were identified as having diabetes, prior CVD, both diabetes and prior CVD, or neither condition. Adults were considered to have had a CV event if they were hospitalized for acute myocardial infarction or stroke, or died of any cause.
From 1994 to 2014, the prevalence of diabetes increased from 3.1% to 9%, and the prevalence of CVD increased from 2.5% to 3.7%.
In 1994, adults with diabetes (RR = 2.06; 95% CI, 2.02-2.1), prior CVD (RR = 2.16; 95% CI, 2.12-2.21) and diabetes plus prior CVD (RR = 3.81; 95% CI, 3.69-3.93) had a higher risk for CV events compared with adults who did not have diabetes or CVD.
CV risk with diabetes reduced over 25 years
In 2014, adults with diabetes (RR = 1.58; 95% CI, 1.56-1.61), prior CVD (RR = 2.06; 95% CI, 2.02-2.1) and both diabetes and prior CVD (RR = 3.1; 95% CI, 3.04-3.17) still had a higher risk for CV events than adults with neither condition. However, CV event rates decreased for all adults, regardless of condition. Adults with diabetes had the largest reduction in event rates in 2014 compared with 1994 (RR = 0.49), followed by adults with neither condition (RR = 0.63), adults with prior CVD (RR = 0.66) and adults with diabetes and prior CVD (RR = 0.69).
“These results suggest that diabetes is still an important CV risk factor but no longer equivalent to CVD — a change that likely reflects the use of modern, multifactorial approaches to diabetes,” the researchers wrote.
Ke said the use of statins, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers to reduce CV complications, improvements in glycemic management and diabetes screening, and the emergence of GLP-1 receptor agonists and SGLT2 inhibitors are all factors that may have contributed to the reduction in CV events.
“Clinically, these findings suggest that changes in practice we have enacted over the past 25 years have probably helped shift trends in the right direction,” Ke said. “Our results are consistent with modern approaches to CV risk reduction being taken up widely and implemented effectively into clinical practice. At the same time, we observed that diabetes remains a strong CV risk factor, and efforts are required to better prevent and manage diabetes and CVD.”
For more information:
Calvin Ke, MD, PhD, can be reached at calvin.ke@utoronto.ca.
Perspective
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Yes, more recent epidemiological data has revealed that type 2 diabetes no longer equals previous cardiovascular disease as a similar predictor of additional CVD events as CVD alone. The JAMA report of administrative health care data from Canada physician- and hospital-based services for Ontario residents examining secular trends in the association of diabetes and prior CVD of adults aged 20 to 84 years old with CV events from 1994 to 2019 supports this claim.
However, some limitations of this analysis need to include the following. First, retrospective studies using databases rather than prospective studies have value, but interpretation of the findings are typically less convincing. Second, the diagnosis of diabetes is medical record-sourced, and specificity of criteria of diagnosis including diabetes type — type 1 vs. type 2 — is not stated. Yes, most adults in this age range will have type 2 diabetes, but patients with type 1 diabetes now live much longer. Third, adjustments for important information related to an explanation for the relative reduced risk of CVD events in patients with diabetes vs. those with a CVD history were not present, ie,. Levels of glycemia (HbA1c), statin therapy and plasma lipids/lipoproteins, blood pressure and frequency of health care provider evaluation.
Overall, the progress made in this relative risk reduction is encouraging, but there remains much to be done.
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