Reducing HbA1c best strategy to avoid initial, subsequent CVD events in type 1 diabetes 

Bebu I, et al. Diabetes Care. 2020;doi:10.2337/dc19-2292.

Intensive glucose management can help adults with type 1 diabetes avoid an initial or subsequent cardiovascular disease or major adverse cardiovascular disease event, according to findings published in Diabetes Care. 

“Availability of continuous glucose monitoring and more precise insulin delivery devices that proactively respond to hypoglycemia has made improved glucose control in individuals with type 1 diabetes more achievable,” Ionut Bebu, PhD, an associate research professor at the biostatistics center of The George Washington University in Rockville, Maryland, and colleagues wrote. “With overall improvements in glycemic control, CVD, the primary cause of death in type 1 diabetes, can be reduced.”

Bebu and colleagues assessed annual HbA1c, triglyceride and HDL cholesterol levels in 1,441 adults with type 1 diabetes from the Diabetes Control and Complications Trial and the Epidemiology of Diabetes Interventions and Complications study (mean age at baseline, 27 years; 47% women). The researchers also identified CVD events, such as CVD death, angina and congestive heart failure, using medical histories and electrocardiograms from 29 years of median follow-up time.

The researchers identified 421 CVD events among 239 participants and 149 major adverse cardiovascular events — including CVD death, nonfatal myocardial infarction or nonfatal stroke — among 120 participants. 

Intensive glucose management can help adults with type 1 diabetes avoid an initial or subsequent cardiovascular disease or major adverse cardiovascular disease event.

The strongest modifiable risk factor was HbA1c, according to the researchers. Each 1% (or in mmol/mol 10 mmol/mol) rise in mean HbA1c increased risk for an initial CVD event by 38% (HR = 1.38; 95% CI, 1.21-1.56), subsequent CVD events by 28% (incidence ratio [IR] = 1.28; 95% CI, 1.09-1.51), an initial major adverse cardiovascular event by 54% (HR = 1.54; 95% CI, 1.3-1.82) and subsequent major adverse CV events by 89% (IR = 1.89; 95% CI, 1.36-2.61). 

In addition, a 5-year increase in age led to greater risks for a CVD event (HR = 1.46; 95% CI, 1.32-1.61), subsequent CVD events (IR = 1.18; 95% CI, 1.07-1.31), a major adverse CV event (HR = 1.53; 95% CI, 1.33-1.75) and subsequent major adverse cardiovascular events (IR = 1.69; 95% CI, 1.2-2.37).

The researchers also found that each 10 mm Hg increase in systolic blood pressure was tied to greater risks for a major adverse CV event (HR = 1.35; 95% CI, 1.11-1.66) and subsequent major adverse CV events (IR = 1.83; 95% CI, 1.14-2.95). The risk for subsequent major adverse CV events (IR = 0.19; 95% CI, 0.06-0.58) was reduced for those who used ACE inhibitors vs. those who did not. 

“HbA1c is a strong predictor of recurrent events alone, as is blood pressure and use of ACE inhibitors,” the researchers wrote. “Therefore, intensive management of glycemia, use of antihypertensive medication, lipid control and smoking prevention/cessation are recommended to lower the risk of initial CVD events in type 1 diabetes.”– by Phil Neuffer

Disclosures: The authors report no relevant financial disclosures.

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Risk Factors for First and Subsequent CVD Events in Type 1 Diabetes: The DCCT/EDIC Study

Ionut Bebu, David Schade, Barbara Braffett, Mikhail Kosiborod, Maria Lopes-Virella, Elsayed Z. Soliman, William H. Herman, David A. Bluemke, Amisha Wallia, Trevor Orchard, John M. Lachin, on behalf of the DCCT/EDIC Research Group

Diabetes Care 2020 Jan; dc192292. https://doi.org/10.2337/dc19-2292

Abstract

OBJECTIVE The Diabetes Control and Complications Trial (DCCT) and its observational follow-up Epidemiology of Diabetes Interventions and Complications (EDIC) demonstrated the dominant role of glycemia, second only to age, as a risk factor for a first cardiovascular event in type 1 diabetes (T1D). We now investigate the association between established risk factors and the total cardiovascular disease (CVD) burden, including subsequent (i.e., recurrent) events.

RESEARCH DESIGN AND METHODS CVD events in the 1,441 DCCT/EDIC participants were analyzed separately by type (CVD death, acute myocardial infarction [MI], stroke, silent MI, angina, percutaneous transluminal coronary angioplasty/coronary artery bypass graft [PTCA/CABG], and congestive heart failure [CHF]) or as composite outcomes (CVD or major adverse cardiovascular events [MACE]). Proportional rate models and conditional models assessed associations between risk factors and CVD outcomes.

RESULTS Over a median follow-up of 29 years, 239 participants had 421 CVD events, and 120 individuals had 149 MACE. Age was the strongest risk factor for acute MI, silent MI, stroke, and PTCA/CABG, while glycemia was the strongest risk factor for CVD death, CHF, and angina, second strongest for acute MI and PTCA/CABG, third strongest for stroke, and not associated with silent MI. HbA_1c was the strongest modifiable risk factor for a first CVD event (CVD: HR 1.38 [95% CI 1.21, 1.56] per 1% higher HbA_1c; MACE: HR 1.54 [1.30, 1.82]) and also for subsequent CVD events (CVD: incidence ratio [IR] 1.28 [95% CI 1.09, 1.51]; MACE: IR 1.89 [1.36, 2.61]).

CONCLUSIONS Intensive glycemic management is recommended to lower the risk of initial CVD events in T1D. After a first event, optimal glycemic control may reduce the risk of recurrent CVD events and should be maintained.