Macrovascular disease and risk factors in youth with type 1 diabetes: time to be more attentive to treatment?

Abstract

Cardiovascular disease remains the leading cause of mortality in patients with type 1 diabetes. Although cardiovascular disease complications are rare until adulthood, pathology and early markers can manifest in adolescence. Whereas advances have been made in the management of microvascular complications of type 1 diabetes, similar progress in reducing macrovascular complications has not been made. The reasons for the absence of progress remain incompletely understood, but most likely relate to the long time needed for cardiovascular disease to manifest clinically and hence for risk factor management to show a clinical benefit, thus allowing inertia to prevail for diagnosis and particularly for targeting risk factors. In this Review, we summarise paediatric data on traditional and novel risk factors of cardiovascular disease, provide an overview of data from previous and current clinical trials, discuss future directions in cardiovascular disease research for paediatric patients with type 1 diabetes, and advocate for the early identification and treatment of cardiovascular disease risk factors as recommended in multiple guidelines.

Figure 1. Possible Long-term CVD Risk Reduction from Risk Factor Control

Figure 1 represents potential long-term risk reduction assuming high benefit from risk factor (LDL-C, BP, BMI and A1c) lowering, and greater risk reduction when therapy initiated at an earlier age / shorter T1D duration. Individual threshold for clinical CVD (represented by the red dotted horizontal lines) can be raised or lowered depending on risk factor profiles.

Figure 2

Cardiovascular Risk Factors in Youth with T1D