Do traditional cardiovascular risk factors solely explain intima-media thickening in youth with type 1 diabetes?

Normal pediatric values of carotid artery intima-media thickness measured by B-mode ultrasound and radiofrequency echo tracking respecting the consensus: a systematic review

BACKGROUND

Carotid artery intima-media thickness (IMT) is a sub-clinical radiologic marker of atherosclerosis in children. It is associated with adult-onset vascular disease.

OBJECTIVE

To determine normal pediatric values of IMT from results observed in the literature.

METHODS

Our systematic review was conducted according to PRISMA guidelines. We reviewed 2298 English articles from inception to February 2023. Inclusion criteria included studies evaluating B-mode and radiofrequency (RF)-based IMT measurements based on the American Heart Association, the Association for European Pediatric Cardiology, the Mannheim Consensus, and the American Society of Echocardiography recommendations. A meta-analysis of aggregate data was conducted to obtain the confidence interval (CI) for IMT, using a 95% confidence level.

RESULTS

We obtained 88 B-mode-based IMT measurement studies with 6184 children and six radiofrequency echo-tracking-based studies with 766 children. Mean IMT in the pediatric population was 0.43 mm, 95% [CI] 0,42 to 0.44, using the B-mode technique, and 0.41 mm, 95% [CI] 0.36 to 0.45 using the radiofrequency technique. No significant relationship was detected between IMT and age (p value = 0.83). Finally, no significant effect of sex on IMT was found (p value = 0.82 for B-mode and p value = 0.62 for RF).

CONCLUSION

Based on the studies selected in this literature review, we were unable to conclude that there was a significant difference between the average IMT of boys and girls. No relationship was demonstrated between age and IMT. IMT is technique-specific, and normal values should be interpreted according to recommendations of recognized consensus to counteract the current heterogeneity in literature.

CLINICAL RELEVANCE STATEMENT

Technique and children-specific Intima media thickness measurements help clinicians and scientists to assess the risk of atherosclerosis in children.

KEY POINTS

• Intima-media thickness (IMT) does not correlate with age in children without risk factors. • According to current literature, there is no difference in IMT between healthy boys and girls. • There is heterogeneity, even with studies abiding by the official consensus.

Differences in lipid and blood pressure measurements between individuals with type 1 diabetes and the general population: a cross-sectional study

OBJECTIVES

Cardiovascular disease (CVD) is a precarious complication of type 1 diabetes (T1D). Alongside glycaemic control, lipid and blood pressure (BP) management are essential for the prevention of CVD. However, age-specific differences in lipid and BP between individuals with T1D and the general population are relatively unknown.

DESIGN

Cross-sectional study.

SETTING

Six diabetes outpatient clinics and individuals from the Lifelines cohort, a multigenerational cohort from the Northern Netherlands.

PARTICIPANTS

2178 adults with T1D and 146 22 individuals without diabetes from the general population.

PRIMARY AND SECONDARY OUTCOME MEASURES

Total cholesterol, low-density lipoprotein cholesterol (LDL-cholesterol), systolic BP (SBP) and diastolic BP (DBP), stratified by age group, glycated haemoglobin category, medication use and sex.

RESULTS

In total, 2178 individuals with T1D and 146 822 without diabetes were included in this study. Total cholesterol and LDL-cholesterol were lower and SBP and DBP were higher in individuals with T1D in comparison to the background population. When stratified by age and medication use, total cholesterol and LDL-cholesterol were lower and SBP and DBP were higher in the T1D population. Men with T1D achieved lower LDL-cholesterol levels both with and without medication in older age groups in comparison to women. Women with T1D had up to 8 mm Hg higher SBP compared with the background population, this difference was not present in men.

CONCLUSIONS

Lipid and BP measurements are not comparable between individuals with T1D and the general population and are particularly unfavourable for BP in the T1D group. There are potential sex differences in the management of LDL-cholesterol and BP.

Cardiovascular risk management in people with type 1 diabetes: performance using three guidelines

INTRODUCTION

Cardiovascular disease (CVD) is the leading cause of mortality in individuals with type 1 diabetes mellitus (T1DM). Cardiovascular risk management is therefore essential in the management of individuals with T1DM. This study describes the performance of lipid and blood pressure management in individuals with T1DM using three guidelines.

RESEARCH DESIGN AND METHODS

Individuals ≥18 years with T1DM, treated with insulin for ≥1 year, visiting Diabeter or the University Medical Center Groningen between January 1, 2018 and December 31, 2018, were included. Lipid and blood pressure management were examined using the Dutch, American Diabetes Association (ADA) and National Institute for Health and Care Excellence (NICE) guidelines. Concordance of recommended and prescribed lipid-lowering (LLM) or antihypertensive medication (AHM) was assessed per guideline and 10-year age groups. Achievement of treatment targets was assessed for those prescribed medication.

RESULTS

A total of 1855 individuals with T1DM were included. LLM and AHM was prescribed in 19% and 17%, respectively. In individuals recommended LLM, this was prescribed in 22%-46% according to Dutch, ADA or NICE guideline recommendations. For individuals recommended AHM, this was prescribed in 52%-75%. Recommended and actual prescription of LLM and AHM increased over age for all three guidelines. However, discordance between treatment recommendation and medication prescribed was higher in younger, compared with older, age groups. Low-density lipoprotein-cholesterol targets were achieved by 50% (without CVD) and 31% (with CVD) of those prescribed LLM. The blood pressure target was achieved by 46% of those prescribed AHM.

CONCLUSION

This study suggests that there is undertreatment of lipid and blood pressure according to guideline recommendations, particularly in younger age groups. Treatment targets are not met by most individuals prescribed medication, while guidelines recommendations differ considerably. We recommend to investigate the factors influencing undertreatment of lipid and blood pressure management in individuals with T1DM.

Undertreatment of hypertension and hypercholesterolaemia in children and adolescents with type 1 diabetes: long-term follow-up on time trends in the occurrence of cardiovascular disease, risk factors and medications use

AIMS

The aims of the present study were, firstly, to evaluate long-term trends in the occurrence and treatment of cardiovascular disease (CVD) risk factors and the occurrence of CVD events in children with type 1 diabetes mellitus (T1DM) and, secondly, to assess the determinants of undertreatment of CVD risk factors.

METHODS

A retrospective cohort study was conducted in 3728 children (<19 years of age) with T1DM and up to 5 age- and gender-matched diabetes-free children (reference cohort) (n = 18 513) using data from the Clinical Practice Research Datalink (CPRD).

RESULTS

Compared with diabetes-free subjects, children with T1DM had significantly higher annual prevalence rates of CVD risk factors and cardiovascular (CV) medication use 20 years after the onset of diabetes (index date): hypertension: 35.2% vs. 11.4%, P < 0.001; hypercholesterolaemia: 66.7% vs. 7.14%, P < 0.001; and CV medication use: 37.0% vs. 3.6%, P < 0.001. The significant differences between prevalence rates in the two cohorts started from 1 year before the index date. Furthermore, 50% of the children in the T1DM cohort with hypertension and 53% with hypercholesterolaemia remained untreated with CV drugs for a period of 2-5 years during the 20-year follow-up. Age was the only determinant associated with undertreated hypertension in the T1DM cohort.

CONCLUSIONS

Children with T1DM had substantially higher prevalence rates of hypertension and hypercholesterolaemia from 1 year before up to 20 years after the onset of diabetes compared with nondiabetics. There is a substantial undertreatment of CVD risk factors with CV drugs. In children with T1DM, screening for CVD risk factors and adequate treatment are of the utmost importance to prevent CVD later in life.