Modifiable cardiometabolic risk factors dominant in type 1 diabetes mortality risk
medwireNews: The strongest predictors for mortality and cardiovascular disease (CV) disease in patients with type 1 diabetes are generally modifiable cardiometabolic risk factors, researchers report.
This suggests that “patients with [type 1 diabetes] who have not developed CV disease, specifically younger patients, might benefit from more aggressive primary CV risk prevention efforts and perhaps initiated earlier in the course of disease,” write Aidin Rawshani (University of Gothenburg, Sweden) and co-authors in Circulation.
Their findings are based on an analysis of data for 32,611 patients (mean age 33.1 years, 46% women) with type 1 diabetes (mean duration 17.9 years) retrieved from the Swedish National Diabetes Register between 1998 and 2014.
During a median 10.4 years of follow-up, 1809 (5.5%) patients died.
By combining Cox regression and machine-learning analyses, Rawshani and team demonstrated that, of the 17 risk factors studied, age was the strongest predictor of the risk for both death and cardiovascular disease (acute myocardial infarction, stroke, and hospitalization for heart failure).
Aside from age, glycated hemoglobin (HbA1c), albuminuria, diabetes duration, systolic blood pressure (BP), and low-density lipoprotein (LDL) cholesterol were all among the top five predictors for all outcomes.
Specifically, the strongest predictors for death were HbA1c, with each mmol/mol increase associated with a 2% increased risk (equating to approximately 22% per 1% HbA1c increase), on average, and micro- or macroalbuminuria, which was associated with a 2.4-fold increased mortality risk.
For acute myocardial infarction, each additional year with diabetes was associated with a 3% increased risk for death, while each mmol/L increase in LDL cholesterol was associated with a 47% increased risk.
Increasing systolic BP and albuminuria were the top two risk factors associated with stroke at hazard ratios (HR) of 1.02 per mmHg and 2.37, respectively, while albuminuria (HR=3.63) and HbA1c (HR=1.03 per mmol/mol) were the most important variables associated with heart failure risk.
The investigators also looked at the optimal levels for HbA1c, systolic BP and LDL cholesterol, and found that lower levels than recommended by contemporary guidelines were associated with lower risk for both death and CV disease, with the exception of HbA1c, ,which had a U-shaped association.
They suggest that determining “whether targeting lower levels may be clinically beneficial should be the focus of future trials.”
Rawshani et al also say their findings indicate that LDL cholesterol “appears to be a more important prognostic factor than previously appreciated.”
They continue: “This is an important clinical point since currently statins are less commonly used in patients with [type 1 diabetes] below the age of 40, and some clinicians remain unconvinced of the merits of statins” in these patients.
By Laura Cowen
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