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The authors of a new review paper said that the management of cardiovascular disease is an often overlooked but important aspect of the care of patients with type 1 diabetes.
Cardiovascular disease is the most common cause of death in type 1 diabetes as well as type 2 diabetes. However, no randomized clinical trial data exist to support his cardiovascular risk interventions specifically for patients with type 1 diabetes.Professional social recommendations Studies aimed at lowering lipids have been developed primarily from trials in people with type 2 diabetes and are conflicting, the review authors said. New England Medical Journal.
Cardiovascular risk management typically receives far less attention than blood sugar control in type 1 diabetes consultations, especially in younger adults, said Camila Manrique, a professor of medicine in the department of endocrinology at the University of Missouri-Columbia and lead author of the review. said Acevedo, MD. Medscape Medical News.
“Type 1 diabetes is, in some ways, what type 2 diabetes was 20 years ago, in the sense that we used to be very glucose-centric, but we almost forgot about cardiovascular risks. “That has completely changed in diabetes. We now know that in type 1 diabetes, blood sugar control is very important, but things like tight blood pressure control and lipid control are not enough,” she said.
One reason for this is the lack of clinical trial evidence for lipid, blood pressure, antithrombotic, and obesity interventions in type 1 diabetes. “Many people with type 1 diabetes are young, so I don't think it's necessarily clear that they are at extremely high cardiovascular risk,” Manrique Acevedo said.
Additionally, achieving tight glycemic control in type 1 diabetes can lead to weight gain, which negatively impacts cardiovascular health. “As you gain more weight, you increase your risk of high blood pressure and other complications from excess weight gain. When we see patients with type 1 diabetes, we want their A1c to be below.” [at target], But excessive weight gain is not always dealt with because it is not easy to deal with. And there is a risk of hypoglycemia. “There are a lot of questions that are being asked, but we don’t yet have all the tools to address them,” she said.
Asked for comment, Viral Shah, M.D., professor of medicine and director of diabetes clinical research at the Center for Diabetes and Metabolic Diseases at Indiana University School of Medicine (Indianapolis), said: Medscape Medical News“For years, we have focused on A1c and microvascular complications in type 1 diabetes, but we have not thought about macrovascular complications. Now is the time to think about that. So I highly recommend that you start thinking about cardiovascular and neurocognitive issues,” especially in middle-aged and older age groups that haven't been talked about before.
Co-authors on Manrique Acevedo's review paper were Il B. Hirsch, MD, professor and director of diabetes care at the University of Washington, Seattle School of Medicine, and Robert H. Eckel, MD, professor emeritus of endocrinology. , Metabolism and Diabetes, University of Colorado Denver Anschutz Medical Campus.
They begin with an overview of the biology of cardiovascular disease in type 1 diabetes. Although many of the mechanisms are thought to be similar to those of type 2 diabetes, there are some differences. For example, obstructive coronary heart disease appears to be less widespread in type 1 than in type 2, but inflammation of blood vessel walls appears to be more prevalent, independent of glycemic control.
And as shown in a six-and-a-half-year follow-up study of this landmark. DCCT, tight glycemic control clearly reduced the risk of cardiovascular events in participants with type 1 diabetes. In contrast, data are conflicting regarding the relationship between glycemic control and cardiovascular risk in type 2 diabetes.
Kidney disease is also closely associated with cardiovascular disease in type 1 diabetes, the authors write.
This review article is based on recommendations for statin use in type 1 diabetes by the American Diabetes Association (ADA), American College of Cardiology (ACC), American Heart Association (AHA), European Society of Cardiology, and the International Heart Association (AHA). are summarized in the article. Society for Child and Adolescent Diabetes (ISPAD).
Both the ADA and ACC-AHA recommend at least moderate-intensity statins for patients with type 1 diabetes aged 40 to 75 years, but the criteria for when to consider high-intensity statin therapy differ. The ADA and ISPAD provide different guidance for youth ages 10 and older. In none of the recommendations she specifically mentions the age range of 18 to her 39 years.
Manrique-Acevedo et al. recommended cardiovascular risk assessment for all patients with type 1 diabetes, including consideration of obtaining a coronary artery calcium (CAC) score. Data suggests that a CAC score of 100 or higher predicts cardiovascular risk.
As a supplement, they provided a clinical scene of a 34-year-old man with type 1 diabetes who was diagnosed at age 10 with no history of cardiovascular disease or symptoms and no albuminuria. His total cholesterol is 210 mg/dL, his low-density lipoprotein (LDL) cholesterol is 125 mg/dL, his high-density lipoprotein (HDL) cholesterol is 45 mg/dL, his triglycerides are 200 mg/dL, and his A1c is It was 7.0%. .
Based on ADA guidance, his diabetes duration and LDL cholesterol “deserve an opportunity to consider recommendations and consider statin therapy with shared decision-making. Alternatively, clinicians should You may also consider measuring your CAC score and/or lipoprotein(a).'' Deciding what to do. ”
Shah said statins are routinely recommended for adults with type 1 diabetes under the age of 40 and those who have had type 1 diabetes for more than 20 years. For those who take it for a short period of time or who do not wish to take statins, we perform a CAC evaluation and recommend statins for those with a score above 100. For others, it will be an individual decision.
he pointed out his data own study We sampled 8,727 adults with type 1 diabetes from the T1D Exchange Clinic registry and demonstrated a 5-year cardiovascular disease incidence of 3.7%. Higher risks were seen with older age, longer duration of diabetes, overweight/obesity, higher A1c, hypertension, dyslipidemia (based on triglyceride/HDL ratio), and nephropathy.
In this study, as in other previous studies, there was no difference in LDL cholesterol levels between those who developed cardiovascular disease and those who did not. “Some hypothesize that the particle size of LDL-C and its oxidation are different in T1D patients and also depend on glycemic control. Therefore, CVD risk is increased in T1D patients even when LDL levels are near normal.” “Reduced CVD risk with statin therapy, regardless of baseline LDL-C levels,” Shah et al. wrote in discussion.
This review includes a second box that summarizes more consensus recommendations on: 1) no increase in hypoglycemia and A1c < 7% if possible; 2) blood pressure control below or above 130/80 mmHg or below 120/80 mmHg with renin-containing therapy. angiotensin-aldosterone blockade, and 3) aspirin as primary prevention in patients over 50 years of age with additional risk factors or as secondary prevention in patients with established atherosclerotic cardiovascular disease 75 - 162 mg.
For obesity management, calorie restriction and increased physical activity aimed at 5% to 10% weight loss, consideration of referral to lifestyle modification programs, and shared decision-making regarding the potential of glucagon-like peptide 1 receptor agonists. Consideration is recommended. Side effects. Bariatric surgery has also been proven to be effective and safe for people with type 1 diabetes and obesity, the researchers noted.
Commenting on recent data showing that type 1 diabetes affects approximately 1 in 200 people in the United States, Manrique Acevedo said, “This is not a rare disease. It's increasing,” he said.
Manrique Acevedo and Ecker had no disclosures. Mr. Hirsch reported grants from Dexcom, Tandem, and MannKind and personal fees from Abbott Diabetes Care, Roche, and Vertex. Mr. Shah reported grants from Nordisk, Alexion and Insulet. Payment or honoraria for presentations from Dexcom, Tandem Diabetes Care, Embecta. Participation in data safety monitoring boards for Dexcom, Novo Nordisk, Sanofi, and Medscape Medical News.
Miriam E. Tucker is a freelance journalist based in the Washington, DC area. She is a regular contributor to her Medscape Medical News, as well as to the Washington Post, NPR's Shots blog, and Diatribe. She's on her X: @MiriamETucker.