Evaluation of cardiovascular risk in adults with type 1 diabetes: poor concordance between the 2019 ESC risk classification and 10-year cardiovascular risk prediction according to the Steno Type 1 Risk Engine

Abstract

Background: Patients with type 1 diabetes (T1D) have higher mortality risk compared to the general population; this is largely due to increased rates of cardiovascular disease (CVD). As accurate CVD risk stratification is essential for an appropriate preventive strategy, we aimed to evaluate the concordance between 2019 European Society of Cardiology (ESC) CVD risk classification and the 10-year CVD risk prediction according to the Steno Type 1 Risk Engine (ST1RE) in adults with T1D.

Methods: A cohort of 575 adults with T1D (272F/303M, mean age 36 ± 12 years) were studied. Patients were stratified in different CVD risk categories according to ESC criteria and the 10-year CVD risk prediction was estimated with ST1RE within each category.

Results: Men had higher BMI, WC, SBP than women, while no difference was found in HbA1c levels between genders. According to the ESC classification, 92.5% of patients aged < 35 years and 100% of patients ≥ 35 years were at very high/high risk. Conversely, using ST1RE to predict the 10-year CVD risk within each ESC category, among patients at very high risk according to ESC, almost all (99%) had a moderate CVD risk according to ST1RE if age < 35 years; among patients aged ≥35 years, the majority (59.1%) was at moderate risk and only 12% had a predicted very high risk by ST1RE. The presence of target organ damage or three o more CV risk factors, or early onset T1D of long duration (> 20 years) alone identified few patients (< 30%) among those aged ≥35 years, who were at very high risk according to ESC, in whom this condition was confirmed by ST1RE; conversely, the coexistence of two or more of these criteria identified about half of the patients at high/very high risk also according to this predicting algorithm. When only patients aged ≥ 50 years were considered, there was greater concordance between ESC classification and ST1RE prediction, since as many as 78% of those at high/very high risk according to ESC were confirmed as such also by ST1RE.

Conclusions: Using ESC criteria, a large proportion (45%) of T1D patients without CVD are classified at very high CVD risk; however, among them, none of those < 35 years and only 12% of those ≥ 35 years could be confirmed at very high CVD risk by the ST1RE predicting algorithm. More studies are needed to characterize the clinical and metabolic features of T1D patients that identify those at very high CVD risk, in whom a very aggressive cardioprotective treatment would be justified.

Keywords: Cardiovascular risk; ESC guidelines; STENO Type 1 risk engine; Type 1 diabetes.

Fig. 1

Cardiovascular risk classification according to 2019 ESC criteria in patients aged < 35 or ≥ 35 years (n = 575). Total (fatal + non fatal) CVD risk was estimated in the total population, stratified by age (< 35 or ≥ 35 years). CVD risk categories were defined according to 2019 ESC guidelines. Very high CVD risk category included T1D patients with a history of CVD, or target organ damage (proteinuria, eGFR < 30 ml/min/1.73 m², left ventricular hypertrophy, or retinopathy), or three or more major CVD risk factors (age > 35 years, hypertension, hypercholesterolemia, smoking, obesity), or early-onset T1D of long duration (> 20 years); high risk category included all patients not included in the very high or the moderate risk category; moderate risk group included young patients (aged < 35 years) with T1D duration < 10 years without other risk factors

Fig. 2

Prediction of CVD events using the Steno type 1 Risk Engine (ST1RE) in a cohort of adults aged ≥ 50 years classified according to 2019 ESC criteria (n = 71). The population over 50 years was classified according to 2019 ESC guidelines into three groups: very high risk, high risk and moderate risk. 10-year CVD risk prediction was estimated with ST1RE