Risk factor control may mitigate excess cardiovascular, mortality risk in type 2 diabetes
medwireNews: A study of the Swedish National Diabetes Register suggests that keeping five cardiovascular risk factor variables within the target ranges could offset the excess risk for death, myocardial infarction, or stroke among patients with type 2 diabetes relative to the general population.
As reported in The New England Journal of Medicine, Aidin Rawshani (Swedish National Diabetes Register, Gothenburg) and colleagues evaluated the risk for these adverse outcomes among 271,174 patients with type 2 diabetes and 1,355,870 controls matched on age, sex, and county.
Patients with diabetes were categorized based on the presence of five risk factors: elevated glycated hemoglobin level (≥7.0% or ≥53 mmol/mol); elevated low-density lipoprotein cholesterol (≥2.5 mmol/L); albuminuria; smoking; and elevated blood pressure (≥140 or ≥80 mmHg for systolic and diastolic blood pressure, respectively).
In all, 13.9% of patients with diabetes and 10.1% of those in the control group died over a median follow-up of 5.7 years. The excess risk for mortality among diabetes patients decreased stepwise for each of the five cardiovascular risk factors that was within the target range, and patients who had none of the risk factors only had a “marginally higher” risk for mortality relative to controls, at a hazard ratio (HR) of 1.06, say the researchers.
Similarly, the risk for acute myocardial infarction and stroke declined with a decreasing number of cardiovascular risk factors, with HRs of 0.84 and 0.95, respectively, for diabetes patients who had none of the risk factors compared with controls.
These findings indicate that “having all five risk-factor variables within the target ranges could theoretically eliminate the excess risk of acute myocardial infarction” among patients with type 2 diabetes, say Rawshani and colleagues. However, they caution that diabetes patients with none of the cardiovascular risk factors still had a significantly elevated risk for hospitalization due to heart failure compared with controls, at a HR of 1.45.
The study authors also found that the excess risk for adverse outcomes associated with cardiovascular risk factors was consistently greater among younger patients with diabetes. Patients aged 80 years or older at baseline who had no cardiovascular risk factors generally had the lowest HRs for mortality, myocardial infarction, and stroke compared with controls, while patients who were aged less than 55 years and had all five risk factors had the highest HRs.
Therefore, “there may be greater potential gains from more aggressive treatment in younger patients with diabetes,” remark Rawshani and team.
Writing in an accompanying editorial, Steven Schroeder (University of California, San Francisco, USA) says that the study findings “provide clear support for active management of risk factors.”
He cautions, however, that “pathways to target levels of risk-factor variables are not always straightforward and often involve issues of lifestyle, adherence to medication, and other behaviors that are hard to modify, despite best attempts.”
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