The Prediction of Atherosclerotic Cardiovascular Disease in Type 1 Diabetes Mellitus: Do We Just Stop Here?

Abstract

Type 1 diabetes mellitus (T1D) is well recognized to be associated with a higher incidence and prevalence of atherosclerotic cardiovascular disease (ASCVD).1 However, randomized clinical trials in which risk factors for ASCVD (blood pressure, lipids, glycemia) have been modified are nonexistent for T1D patients. Thus, any model that is developed must be based on observational data only. The Steno Risk Engine, as described in this issue of Circulation ,2 is the second attempt at estimating ASCVD risk in T1D patients and differs somewhat in design and application from that previously created from the Swedish National Diabetes Register (NDR).3 Article, see p 1058 The Swedish NDR study was based on a model derived from 3661 T1D patients, with >90% having no history of ASCVD over a 5-year interval wherein 197 fatal/nonfatal ASCVD events (myocardial infarction or stroke) occurred. Nonfatal coronary heart disease was defined as nonfatal myocardial infarction, unstable angina, percutaneous coronary intervention, and/or coronary artery bypass grafting, whereas stroke was defined as fatal or nonfatal cerebral infarction or subarachnoid hemorrhage, or was unspecified. In the Swedish study, the hazard ratios for significant predictors of an ASCVD event were previous cardiovascular disease, 3.51; diabetes duration, 2.76; smoking, 1.76; macroalbuminuria (>200 μg/min), 1.52; age of onset of T1D, 1.47; log ratio total cholesterol:high-density lipoprotein cholesterol, 1.26; log hemoglobin A1c (HbA1c), 1.19; and log systolic blood pressure, 1.17. With the use of all 8 variables, the predicted 5-year risk was 5.4±7.9% with a C-statistic of 0.83. In contrast, the Steno Risk Engine was entirely a primary prevention model of first fatal/nonfatal cardiovascular disease (CVD) events that included ischemic heart disease, ischemic stroke, heart failure, and peripheral arterial disease from 4306 T1D patients, and it included ASCVD risk factors similar to the Swedish study + lifestyle. Over a median follow-up of …