Cardiovascular Disease in Type 1 Diabetes Mellitus: Epidemiology and Management of Cardiovascular Risk

Metabolic health in people living with type 1 diabetes in Belgium: a repeated cross-sectional study

AIMS/HYPOTHESIS

Metabolic abnormalities such as central obesity, insulin resistance, dyslipidaemia and hypertension, often referred to as 'the metabolic syndrome' (or 'combined metabolic abnormalities'), are increasingly being identified in people living with type 1 diabetes, accelerating the risk for CVD. As a result, in recent years, treatment in people living with type 1 diabetes has shifted to improving overall metabolic health rather than glucose control alone. In Belgium, diabetes care for people living with type 1 diabetes is centrally organised. The Initiative for Quality Improvement and Epidemiology in Diabetes, imposed by the Belgian health insurance system, has systematically collected data from patients on intensive insulin therapy treated in all 101 diabetes clinics in Belgium since 2001. The aim of this real-world study is to describe the evolution of treatment and metabolic health, including the prevalence of obesity and combined metabolic abnormalities, in people living with type 1 diabetes over the past 20 years, and to compare the treatment and prevalence of complications between those with and without combined metabolic abnormalities.

METHODS

We analysed data on adults (≥16 years old) living with type 1 diabetes, who were diagnosed at age ≤45 years and who had a diabetes duration ≥1 year, collected between 2001 and 2022. The evolution of HbA1c, BMI, LDL-cholesterol, systolic BP, lipid-lowering therapy and antihypertensive therapy over time was analysed. The prevalence of individual and multiple metabolic abnormalities according to various definitions of the metabolic syndrome/combined metabolic abnormalities was analysed, and the association between combined metabolic abnormalities and metabolic health indicators, complications and treatment was investigated in the 2022 data.

RESULTS

The final dataset consisted of 26,791 registrations of adults living with type 1 diabetes collected between 2001 and 2022. Although glycaemic and lipid control generally improved over time, the prevalence of obesity strongly increased (12.1% in 2001 vs 21.7% in 2022, p<0.0001), as did the presence of combined metabolic abnormalities (WHO criteria: 26.9% in 2001 vs 42.9% in 2022 in women, p<0.0001; 30.4% in 2001 vs 52.1% in 2022 in men, p<0.0001; WHO criteria without albuminuria: 22.3% in 2001 vs 40.6% in 2022 in women, p<0.0001; 25.1% in 2001 vs 49.2% in 2022 in men, p<0.0001; NCEP-ATPIII criteria: 39.9% in 2005 vs 57.2% in 2022 in women, p<0.0001; 40.8% in 2005 vs 60.9% in 2022 in men, p<0.0001; IDF criteria: 43.9% in 2005 vs 59.3% in 2022 in women, p<0.001; 33.7% in 2005 vs 50.0% in 2022 in men, p<0.0001). People with combined metabolic abnormalities had higher glucose levels compared to those without combined metabolic abnormalities (HbA1c >58 mmol in men: 48.9% vs 36.9%; HbA1c >58 mmol in women: 53.3% vs 41.1%, p<0.0001). People with combined metabolic abnormalities were more often treated with adjunct therapies such as metformin, sodium-glucose transport protein 2 inhibitors and glucagon-like peptide-1 receptor agonists. In both men and women, the presence of combined metabolic abnormalities was strongly related to the presence of eye complications, peripheral neuropathy, chronic kidney disease and CVD, corrected for age, diabetes duration and HbA1c.

CONCLUSIONS/INTERPRETATION

Overweight, obesity and combined metabolic abnormalities are increasingly being identified in people living with type 1 diabetes, further accelerating the risk of microvascular and macrovascular complications. Early identification of the presence of combined metabolic abnormalities should enable therapeutic interventions to be modified towards multifactorial approaches, with attention to education on avoidance of overweight (e.g. dietary counselling) in addition to strict glycaemic control and intensification of use of antihypertensive agents and statins. Use of adjunct therapies in this population as a tool should be explored more thoroughly to reduce risk of complications.

Strategies for Cardiovascular Disease Prevention in Type 1 Diabetes: A Comprehensive Review

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality among individuals with type 1 diabetes (T1D), necessitating effective prevention strategies. This comprehensive review consolidates current knowledge and evidence on preventing CVD in T1D patients. It begins by exploring the pathophysiological mechanisms that link T1D to an increased risk of CVD, highlighting factors such as chronic hyperglycemia, hypertension, dyslipidemia, and inflammation. The review also examines the epidemiology and specific risk factors for CVD in this population, emphasizing the need for rigorous risk assessment and screening. Lifestyle modifications, including dietary interventions, regular physical activity, and smoking cessation, are evaluated for their effectiveness in reducing CVD risk. Additionally, the review discusses pharmacological interventions, such as insulin therapy for glycemic control, antihypertensive medications, lipid-lowering agents, and antiplatelet therapy, underscoring their critical role in CVD prevention. Emerging therapies and future research directions are explored, focusing on novel pharmacological agents, advances in insulin delivery systems, and personalized medicine approaches. The importance of integrated care models involving multidisciplinary teams and the use of technology is highlighted as essential for comprehensive management. Challenges and barriers to implementing these strategies, including healthcare system limitations, patient adherence, and socioeconomic factors, are also addressed. This review provides a detailed synthesis of current strategies and future directions for preventing CVD in individuals with T1D, serving as a valuable resource for clinicians, researchers, and policymakers dedicated to improving cardiovascular outcomes in this high-risk population.

Assessment of arterial stiffness in paediatric patients with type 1 diabetes mellitus

AIMS

To investigate early indicators of cardiovascular disease (CVD) in children and adolescents with type 1 diabetes mellitus (T1DM), focusing on pulse wave velocity (PWV) and its associations with various anthropometric and glycemic parameters.

PATIENTS AND METHODS

A total of 124 children and adolescents with T1D (mean age 10.75 ± 3.57 years) were included in this cross-sectional study. Anthropometric data, including height, weight, body mass index (BMI), glycemic parameters, such as HbA1c and time in range (TIR) were assessed. PWV was assessed by oscillometric method using the Mobil-O-Graph PWA device. Univariate and multivariate linear regression were used to explore the association of PWV z-score with anthropometric, demographic, and glycaemic variables.

RESULTS

Significant negative association between PWV and age and height (β = -0.336, 95 % CI -0.44 to -0.25, p < 0.001 and β = -0.491, 95 % CI -0.62 to -0.36, p < 0.001, respectively), while gender showed a significant positive association with PWV, with females displaying higher PWV values compared to males (β = 0.366, 95 % CI 0.17 to 0.56, p < 0.001). TIR was positively associated with PWV (β = 0.092, 95 % CI 0.01 to 0.16, p = 0.017 only for patients having TIR ≤ 50 %. Finally, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were positively associated with PWV (β = 0.086, 95 % CI 0.02 to 0.14, p = 0.007 and β = 0.152, 95 % CI 0.07 to 0.23, p < 0.001, respectively).

CONCLUSION

Youth with T1DM who spend <50 % of time in range exhibit uniquely increased signs of arterial stiffness, indicating that poor glycemic control may contribute to early vascular damage. Differences related to age, gender and height should be considered.

The Burden of Inpatient Hospitalizations with Cardiac and Cerebrovascular Diseases in Patients with Type 1 Diabetes: Insights from the National Inpatient Sample in the US

BACKGROUND

This study aimed to evaluate the burden and impact of cardiac and cerebrovascular disease (CCD) on hospital inpatients with type 1 diabetes mellitus (T1DM).

METHODS

This is a retrospective nationwide cohort study of people with T1DM with or without CCD in the US National Inpatient Sample between 2016 and 2019. The in-hospital mortality rates, length of stay (LoS), and healthcare costs were determined.

RESULTS

A total of 59,860 T1DM patients had a primary diagnosis of CCD and 1,382,934 did not. The median LoS was longer for patients with CCD compared to no CCD (4.6 vs. 3 days). Patients with T1DM and CCD had greater in-hospital mortality compared to those without CCD (4.1% vs. 1.1%, p < 0.001). The estimated total care cost for all patients with T1DM with CCD was approximately USD 326 million. The adjusted odds of mortality compared to patients with non-CCD admission was greatest for intracranial hemorrhage (OR 17.37, 95%CI 12.68-23.79), pulmonary embolism (OR 4.39, 95%CI 2.70-7.13), endocarditis (OR 3.46, 95%CI 1.22-9.84), acute myocardial infarction (OR 2.31, 95%CI 1.92-2.77), and stroke (OR 1.47, 95%CI 1.04-2.09).

CONCLUSIONS

The burden of CCD in patients with T1DM is substantial and significantly associated with increased hospital mortality and high healthcare expenditures.

Microalbuminuria and lipid variations in adolescents diagnosed with type 1 diabetes

Objective

This study investigates the prevalence of lipid abnormalities among adolescents diagnosed with Type 1 Diabetes Mellitus (T1DM) and explores potential associations with microalbuminuria and cardiovascular disease (CVD) risk factors.Research Design and Methods: A retrospective study analyzed lipid profiles, microalbuminuria, and CVD risk in adolescents with T1DM. Six hundred individuals were assessed for lipid levels, BMI, and microalbuminuria.

Results

Dyslipidemia prevalence was 59.7 %, with 22.7 % exhibiting abnormal total cholesterol (TC) and triglycerides (TG), and 15.8 % with elevated TC alone. A2 microalbuminuria was found in 59.2 %, with 14.6 % showing A3. Females had higher A2 prevalence and mild eGFR decrease (P = 0.02). Lipid levels correlated significantly with microalbuminuria (TC: r = 0.761; TG: r = 0.572, P = 0.03 and 0.04, respectively). The prevalence of high total cholesterol (TC) + high triglycerides (TG), as well as the high TG alone, was considerably higher in patients belonging to the A2 Microalbuminuria group. AIP, HbA1c, and UACR showed a strong positive correlation (r = 0.542, P = 0.04; r = 0.621, P = 0.02).

Conclusion

Our study highlights the prevalence of elevated or borderline lipid levels among adolescents with Type 1 Diabetes Mellitus (T1DM), indicating a heightened risk of dyslipidemia in this population. Particularly concerning is the significantly increased incidence of dyslipidemia among young individuals with T1DM, with females exhibiting a notable susceptibility to cardiovascular disease (CVD) due to dyslipidemia's impact on the Atherogenic Index of Plasma (AIP). Furthermore, Microalbuminuria, specifically type A2 and A3, was prevalent among our study participants, with females showing a significantly higher occurrence of A2 microalbuminuria compared to males. The association between microalbuminuria and dyslipidemia, especially the combination of high total cholesterol (TC) and high triglycerides (TG), emphasizes the importance of comprehensive screening protocols for both microalbuminuria and dyslipidemia in managing the cardiovascular risk profile of individuals with T1DM.

Association of CIITA (rs8048002) and CLEC2D (rs2114870) gene variants and type 1 diabetes mellitus

Background

Type I diabetes mellitus (T1DM) is a significant health challenge, especially for children, owing to its chronic autoimmune nature. Although the exact etiology of T1DM remains elusive, the interplay of genetic predisposition, immune responses, and environmental factors are postulated. Genetic factors control immune reactivity against β-cells. Given the pivotal roles of CIITA and CLEC2D genes in modulating a variety of immune pathologies, we hypothesized that genetic variations in CIITA and CLEC2D genes may impact T1DM disease predisposition. This study was designed to explore the association between gene polymorphisms in CIITA (rs8048002) and CLEC2D (rs2114870) and type 1 diabetes (T1DM), with a focus on analyzing the functional consequence of those gene variants.

Methods

The study enlisted 178 healthy controls and 148 individuals with type 1 diabetes (T1DM) from Suez Canal University Hospital. Genotyping for CIITA and CLEC2D was done using allelic-discrimination polymerase chain reaction (PCR). Levels of glycated hemoglobin (HbA1c) and lipid profiles were determined through automated analyzer, while fasting blood glucose and insulin serum levels were measured using the enzyme-linked immunosorbent assay (ELISA) technique. RegulomeDB was used to examine the regulatory functions of CIITA (rs8048002) and CLEC2D (rs2114870) gene variants.

Results

Analysis of the genotype distribution of the CIITA rs8048002 polymorphism revealed a significantly higher prevalence of the rare C allele in T1DM patients compared to the control group (OR = 1.77; P = 0.001). Both the CIITA rs8048002 heterozygote TC genotype (OR = 1.93; P = 0.005) and the rare homozygote CC genotype (OR = 3.62; P = 0.006) were significantly more frequent in children with T1DM when compared to the control group. Conversely, the rare A allele of CLEC2D rs2114870 was found to be significantly less frequent in T1DM children relative to the control group (OR = 0.58; P = 0.002). The heterozygote GA genotype (OR = 0.61; P = 0.033) and the rare homozygote AA genotype (OR = 0.25; P = 0.004) were also significantly less frequent in T1DM patients compared to the control group. Both CIITA (rs8048002) and CLEC2D (rs2114870) gene variants were predicted to have regulatory functions, indicated by a RegulomeDB score of (1f) for each.

Conclusion

The rare C allele of CIITA rs8048002 genetic variant was associated with an increased risk of developing T1DM, while the less common A allele of CLEC2D rs2114870 was associated with a reduced risk of T1DM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01402-w.

Crosstalk between Inflammation and Atherosclerosis in Rheumatoid Arthritis and Systemic Lupus Erythematosus: Is There a Common Basis?

Cardiovascular disease is the leading cause of morbidity and mortality in patients with rheumatoid arthritis and systemic lupus erythematosus. Traditional cardiovascular risk factors, although present in lupus and rheumatoid arthritis, do not explain such a high burden of early cardiovascular disease in the context of these systemic connective tissue diseases. Over the past few years, our understanding of the pathophysiology of atherosclerosis has changed from it being a lipid-centric to an inflammation-centric process. In this review, we examine the pathogenesis of atherosclerosis in systemic lupus erythematosus and rheumatoid arthritis, the two most common systemic connective tissue diseases, and consider them as emblematic models of the effect of chronic inflammation on the human body. We explore the roles of the inflammasome, cells of the innate and acquired immune system, neutrophils, macrophages, lymphocytes, chemokines and soluble pro-inflammatory cytokines in rheumatoid arthritis and systemic lupus erythematosus, and the roles of certain autoantigens and autoantibodies, such as oxidized low-density lipoprotein and beta2-glycoprotein, which may play a pathogenetic role in atherosclerosis progression.

Navigating Cardiovascular Risk in Type 1 Diabetes: A Comprehensive Review of Strategies for Prevention and Management

Type 1 diabetes mellitus (T1DM) poses a significant cardiovascular risk, necessitating comprehensive prevention and management strategies. This review provides insights into the cardiovascular risk landscape in T1DM, emphasizing the importance of glycemic control, lipid management, blood pressure regulation, and lifestyle modifications. Pharmacological interventions, including insulin therapy and lipid-lowering medications, are discussed alongside lifestyle interventions such as diet, exercise, and smoking cessation. Early detection and management of cardiovascular complications are essential, highlighting the need for regular screening and multidisciplinary care. Patient-centered approaches, including shared decision-making and psychosocial support, are vital to effective care delivery. The review concludes with a call to action for healthcare providers and policymakers to prioritize cardiovascular risk management in T1DM. It explores future directions, including emerging therapies and technological innovations. By implementing evidence-based strategies and fostering collaboration across disciplines, we can mitigate cardiovascular risk and improve outcomes for individuals with T1DM.

The effect of physical activity on cytokine levels in adults living with type 1 diabetes-a preliminary study

The aim of this study is to investigate whether physical activity and the level of body fat are factors reducing the level of pro-inflammatory cytokines in people with T1DM. Twenty-five men (27.8 ± 9.4 years old; 178.9 ± 6.9 cm; 80.6 ± 12 kg) and 18 women (28.1 ± 12.5 years old; 162.4 ± 5.5; 63.1 ± 9.9 kg) were divided into four groups based on body fat percentage and level of physical activity (AN-active people with normal body fat; IAN-inactive people with normal body fat; AO-active people with excessive body fat, IAO-inactive people with excessive body fat). The level of cytokines in the blood serum was assessed. The level of IL-8 was higher (measurable) in inactive men, regardless of adiposity degree and in women, only in the inactive group with normal body fat. IL-6 was found only in active men with excessive adiposity. In conclusion, the findings from this study allow to indicate that moderate level of physical activity may contribute to a reduction in the development of systemic low-grade inflammation in patients with T1DM, and thus, may reduce the risk of CVD.

PCSK9 plasma concentration is associated with epicardial adipose tissue volume and metabolic control in patients with type 1 diabetes

Patients with type 1 diabetes (T1D) have a greater risk of cardiovascular disease. Proconvertase subtilisin-kexin 9 (PCSK9) is involved in the atherosclerosis process. This study aimed to determine the relationship between PCSK9 levels and epicardial adipose tissue (EAT) volume and cardiometabolic variables in patients with T1D. This was an observational cross-sectional study including 73 patients with T1D. Clinical, biochemical and imaging data were collected. We divided the patients into two groups according to their glycemic control and the EAT index (iEAT) percentile. We performed a correlation analysis between the collected variables and PCSK9 levels; subsequently, we performed a multiple regression analysis with the significant parameters. The mean age was 47.6 ± 8.5 years, 58.9% were men, and the BMI was 26.9 ± 4.6 kg/m2. A total of 31.5%, 49.3% and 34.2% of patients had hypertension, dyslipidemia and smoking habit, respectively. The PCSK9 concentration was 0.37 ± 0.12 mg/L, which was greater in patients with worse glycemic control (HbA1c > 7.5%), dyslipidemia and high EAT volume (iEAT > 75th percentile). The PCSK9 concentration was positively correlated with age (r = 0.259; p = 0.027), HbA1c (r = 0.300; p = 0.011), insulin dose (r = 0.275; p = 0.020), VLDL-C level (r = 0.331; p = 0.004), TG level (r = 0.328; p = 0.005), and iEAT (r = 0.438; p < 0.001). Multiple regression analysis revealed that 25% of the PCSK9 variability was explained by iEAT and HbA1c (p < 0.05). The PCSK9 concentration is associated with metabolic syndrome parameters, poor glycemic control and increased EAT volume in patients with T1D.

Cardiovascular Risk Factors in Adolescents with Type 1 Diabetes: Prevalence and Gender Differences

Objective

Cardiovascular diseases (CVD) are the most important cause of morbidity and mortality in patients with type 1 diabetes (T1D). Children with T1D have a similar or higher prevalence of being overweight (OW) or obese (Ob) compared to healthy peers. The aim of this study was to determine the prevalence of CVD risk factors in children and adolescents with T1D and the impact of obesity and sex differences on these factors.

Methods

Data of patients aged 10-21 years and who had been using intensive insulin therapy with a diagnosis of T1D for at least three years were evaluated. Patients were divided into normal weight (NW), OW and Ob groups based on body mass index percentiles. Risk factors for CVD (obesity, dyslipidemia, hypertension) were compared between groups, and impact of gender was also analyzed.

Results

Data of 365 patients (200 girls, 54.8%), were evaluated. Prevalence of OW/Ob was 25.9% and was significantly higher in girls (30.6% vs 20.1%, p<0.001). Rate of hypertension was highest in OW/Ob girls followed by OW/Ob boys, and similar in NW girls and boys (p=0.003). Mean low density lipoprotein cholesterol (LDL-c) and triglyceride (TG) levels were highest in OW/Ob girls, followed by OW/Ob boys, NW girls and NW boys, respectively (p<0.001 and p<0.001, respectively). Mean high density lipoprotein-cholesterol (HDL-c) levels were similar among groups. Rates of high LDL-c and TG were similar between OW/Ob girls and boys and higher than NW girls, followed by NW boys (p<0.001 and p<0.001, respectively). The rate of low HDL-c was similar in OW/Ob girls and boys, and higher than NW girls, followed by NW boys (p<0.001). Overall, girls were 1.9 times more likely than boys to have two or more risk factors for CVD. Factors associated with risk for CVD in multiple logistic regression analyses were being a girl, followed by higher daily insulin dose, higher hemoglobin A1c, and longer duration of diabetes (r=0.856; p<0.001).

Conclusion

In spite of the increased prevalence for obesity in both sexes, the trend for CVD risk factors was greater in Ob girls, followed by Ob boys and NW girls. Girls with T1D are more likely to be OW/Ob and to have CVD risk than boys, highlighting the need for early intervention and additional studies to elucidate the causes.

All-cause mortality and risk factors in patients with type 1 diabetes in Castilla-La Mancha, Spain. DIACAM1 2010-2020 study

INTRODUCTION

Despite better treatments and care for patients with type 1 diabetes (T1DM), all-cause and cardiovascular mortality still remains higher compared to the general population. We evaluated mortality and risk factors for mortality in a representative cohort of patients with T1DM.

METHODS

DIACAM1 was a cross-sectional, multicenter study on adult patients (≥ 16 years old) and diabetes with at least 5 years since diabetes diagnosis conducted between 2009 and 2010. DIACAM1 2010-2020 study was a follow-up study, extension of DIACAM1, where vital status of patients was evaluated between June 2019 and June 2020.

RESULTS

4.03% [CI95%, 2.53-5.62) of the 1465 patients with T1DM included in the cohort of the DIACAM1 in 2010 had died. Survival was lower than in the sex- and age-matched general population in the same region. 40.7% of deaths were due to cardiovascular disease. HbA1c levels < 7% and triglyceride levels < 150 mg/dL were associated with lower mortality, whereas retinopathy and plasma creatinine were associated with increased mortality.

CONCLUSIONS

We confirmed a lower survival in people with T1DM, with cardiovascular disease being the main cause of mortality. High HbA1c, high triglycerides, retinopathy, and high creatinine are factors associated with mortality.

MiniMed 780G™ advanced hybrid closed-loop system performance in Egyptian patients with type 1 diabetes across different age groups: evidence from real-world users

BACKGROUND

Advanced hybrid closed loop (AHCL) system provides both automated basal rate and correction boluses to keep glycemic values in a target range.

OBJECTIVES

To evaluate the real-world performance of the MiniMed™ 780G system among different age groups of Egyptian patients with type 1diabetes.

METHODS

One-hundred seven AHCL system users aged from 3 to 71 years were enrolled. Data uploaded by patients were aggregated and analyzed. The mean glucose management indicator (GMI), percentage of time spent within glycemic ranges (TIR), time below range (TBR) and time above range (TAR) were determined.

RESULTS

Six months after initiating Auto Mode, patients spent a mean of 85.31 ± 22.04% of the time in Auto Mode (SmartGuard) and achieved a mean GMI of 6.95 ± 0.58% compared with 7.9 ± 2.1% before AHCL initiation (p < 0.001). TIR 70-180 mg/dL was increased post-AHCL initiation from 63.48 ± 10.14% to 81.54 ± 8.43% (p < 0.001) while TAR 180-250 mg/dL, TAR > 250 mg/dL, TBR < 70 mg/dL and TBR < 54 mg/dL were significantly decreased (p < 0.001). After initiating AHCL, TIR was greater in children and adults compared with adolescents (82.29 ± 7.22% and 83.86 ± 9.24% versus 78.4 ± 7.34%, respectively; p < 0.05). The total daily dose of insulin was increased in all age groups primarily due to increased system-initiated insulin delivery including auto correction boluses and basal insulin.

CONCLUSIONS

MiniMed™ 780G system users across different age groups achieved international consensus-recommended glycemic control with no serious adverse effects even in challenging age group as children and adolescents.

SGLT2i and GLP-1 RA therapy in type 1 diabetes and reno-vascular outcomes: a real-world study

AIMS/HYPOTHESIS

Insulin is the primary treatment for type 1 diabetes. However, alternative glucose-lowering therapies are used adjunctively, but importantly are off-label in type 1 diabetes. Little work has previously been undertaken to evaluate safety with long-term efficacy and cardio-renal benefits of such therapies. We sought to investigate the real-world impact of sodium-glucose cotransporter 2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonist (GLP-1 RA) therapy in individuals with type 1 diabetes in relation to effect on blood glucose levels, adverse events and cardio-renal outcomes.

METHODS

We performed a retrospective cohort study of all patients aged 18 or over with type 1 diabetes on the TriNetX platform, a global collaborative network providing access to real-time, anonymised medical records. We included patients who had been treated with an SGLT2i or GLP-1 RA for at least 6 months and analysed the efficacy, safety and cardio-renal outcomes 5 years after initiation of therapy.

RESULTS

We identified 196,691 individuals with type 1 diabetes, 13% of whom were treated with adjunctive glucose-lowering therapy in addition to insulin. Included in the core analysis were 1822 patients treated with a GLP-1 RA and 992 individuals treated with an SGLT2i. Both agents provided clinically meaningful reductions in HbA1c (-2.6 mmol/mol [-0.2%] with SGLT2i and -5.4 mmol/mol [-0.5%] with GLP-1 RA). The SGLT2i treated cohort showed preservation of eGFR over a 5-year period compared with the GLP-1 RA treated cohort (+3.5 ml/min per 1.73 m2 vs -7.2 ml/min per 1.73 m2, respectively), including patients with established chronic kidney disease (CKD). The SGLT2i treated cohort experienced higher rates of diabetic ketoacidosis (DKA) (RR 2.08 [95% CI 1.05, 4.12] p=0.0309) and urinary tract infection/pyelonephritis (RR 2.27 [95% CI 1.12, 4.55] p=0.019) compared with the GLP-1 RA treated cohort. However, the SGLT2i treated cohort were less likely to develop heart failure (RR 0.44 [95% CI 0.23, 0.83] p=0.0092), CKD (RR 0.49 [95% CI 0.28, 0.86] p=0.0118) and be hospitalised for any cause (RR 0.59 [95% CI 0.46, 0.76] p≤0.0001) when compared with the GLP-1 RA treated cohort.

CONCLUSIONS/INTERPRETATION

Both SGLT2is and GLP-1 RAs have potential benefits as adjunctive agents in type 1 diabetes. SGLT2is provide cardio-renal benefits, despite an increase in the risk of DKA and urinary tract infection compared with GLP-1 RA therapy. Long-term evaluation of the efficacy and safety of these adjunctive therapies is required to guide their use in individuals with type 1 diabetes.

Type 1 Diabetes Impairs Endothelium-Dependent Relaxation Via Increasing Endothelial Cell Glycolysis Through Advanced Glycation End Products, PFKFB3, and Nox1-Mediated Mechanisms

BACKGROUND

Type 1 diabetes (T1D) is a major cause of endothelial dysfunction. Although cellular bioenergetics has been identified as a new regulator of vascular function, whether glycolysis, the primary bioenergetic pathway in endothelial cells (EC), regulates vascular tone and contributes to impaired endothelium-dependent relaxation (EDR) in T1D remains unknown.

METHODS

Experiments were conducted in Akita mice with intact or selective deficiency in EC PFKFB3 (6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase 3), the main regulator of glycolysis. Seahorse analyzer and myography were employed to measure glycolysis and mitochondrial respiration, and EDR, respectively, in aortic explants. EC PFKFB3 (Ad-PFKFB3) and glycolysis (Ad-GlycoHi) were increased in situ via adenoviral transduction.

RESULTS

T1D increased EC glycolysis and elevated EC expression of PFKFB3 and NADPH oxidase Nox1 (NADPH oxidase homolog 1). Functionally, pharmacological and genetic inhibition of PFKFB3 restored EDR in T1D, while in situ aorta EC transduction with Ad-PFKFB3 or Ad-GlycoHi reproduced the impaired EDR associated with T1D. Nox1 inhibition restored EDR in aortic rings from Akita mice, as well as in Ad-PFKFB3-transduced aorta EC and lactate-treated wild-type aortas. T1D increased the expression of the advanced glycation end product precursor methylglyoxal in the aortas. Exposure of the aortas to methylglyoxal impaired EDR, which was prevented by PFKFB3 inhibition. T1D and exposure to methylglyoxal increased EC expression of HIF1α (hypoxia-inducible factor 1α), whose inhibition blunted methylglyoxal-mediated EC PFKFB3 upregulation.

CONCLUSIONS

EC bioenergetics, namely glycolysis, is a new regulator of vasomotion and excess glycolysis, a novel mechanism of endothelial dysfunction in T1D. We introduce excess methylglyoxal, HIF1α, and PFKFB3 as major effectors in T1D-mediated increased EC glycolysis.

Risk factors in cardiovascular patients: Challenges and opportunities to improve secondary prevention

BACKGROUND

Effective management of major cardiovascular risk factors is of great importance to reduce mortality from cardiovascular disease (CVD). The Survey of Risk Factors in Coronary Heart Disease (SURF CHD) II study is a clinical audit of the recording and management of CHD risk factors. It was developed in collaboration with the European Association of Preventive Cardiology and the European Society of Cardiology (ESC). Previous studies have shown that control of major cardiovascular risk factors in patients with established atherosclerotic CVD is generally inadequate. Azerbaijan is a country in the South Caucasus, a region at a very high risk for CVD.

AIM

To assess adherence to ESC recommendations for secondary prevention of CVD based on the measurement of both modifiable major risk factors and their therapeutic management in patients with confirmed CHD at different hospitals in Baku (Azerbaijan).

METHODS

Six tertiary health care centers participated in the SURF CHD II study between 2019 and 2021. Information on demographics, risk factors, physical and laboratory data, and medications was collected using a standard questionnaire in consecutive patients aged ≥ 18 years with established CHD during outpatient visits. Data from 687 patients (mean age 59.6 ± 9.58 years; 24.9% female) were included in the study.

RESULTS

Only 15.1% of participants were involved in cardiac rehabilitation programs. The rate of uncontrolled risk factors was high: Systolic blood pressure (BP) (SBP) (54.6%), low-density lipoprotein cholesterol (LDL-C) (86.8%), diabetes mellitus (DM) (60.6%), as well as overweight (66.6%) and obesity (25%). In addition, significant differences in the prevalence and control of some risk factors [smoking, body mass index (BMI), waist circumference, blood glucose (BG), and SBP] between female and male participants were found. The cardiovascular health index score (CHIS) was calculated from the six risk factors: Non- or ex-smoker, BMI < 25 kg/m2, moderate/vigorous physical activity, controlled BP (< 140/90 mmHg; 140/80 mmHg for patients with DM), controlled LDL-C (< 70 mg/dL), and controlled BG (glycohemoglobin < 7% or BG < 126 mg/dL). Good, intermediate, and poor categories of CHIS were identified in 6%, 58.3%, and 35.7% of patients, respectively (without statistical differences between female and male patients).

CONCLUSION

Implementation of the current ESC recommendations for CHD secondary prevention and, in particular, the control rate of BP, are insufficient. Given the fact that patients with different comorbid pathologies are at a very high risk, this is of great importance in the management of such patients. This should be taken into account by healthcare organizers when planning secondary prevention activities and public health protection measures, especially in the regions at a high risk for CVD. A wide range of educational products based on the Clinical Practice Guidelines should be used to improve the adherence of healthcare professionals and patients to the management of CVD risk factors.

Comparison of coronary artery calcium score and cardiovascular risk-stratification by European Society of Cardiology Guidelines and Steno Type 1 Risk Engine in statin-naïve adults with type 1 diabetes

BACKGROUND

Coronary artery calcium (CAC) is a marker of atherosclerotic cardiovascular disease (CVD). However, for patients with type 1 diabetes (T1D), its relationship with T1D-specific cardiovascular (CV) risk-stratification tools is unknown.

AIMS

Assess prevalence of CAC and evaluate relationship between CAC and T1D-specific CV risk-stratification methods in T1D.

METHODS

Cross-sectional study of adults with T1D age 20-60 years, statin-naïve and no history of CVD. Data was obtained from electronic medical records and by interview. Presence of CAC was assessed using non-contrast cardiac computed tomography and quantified by Agatston Units (AU). CV risk-stratification was assessed using the 2019 European Society of Cardiology (ESC) Guidelines and the Steno T1 Risk Engine (ST1RE).

RESULTS

85 patients were included with mean age 35.4 ± 10.3 years, HbA1c 8.3 ± 1.5 % and T1D duration 17.0 ± 10.1 years. 67 patients (78.9 %) had a CAC score of 0 AU, 17 (20.0 %) >0-100 AU, and one (1.2 %) >100 AU. Duration of T1D (p = 0.009), body mass index (p = 0.029), neuropathy (p = 0.016) and low-density lipoprotein cholesterol levels (p = 0.016) were independently associated with a positive CAC score on multivariate analysis. Positive predictive value for a positive CAC score was 85.7 % for the ST1RE high risk category and 31.3 % for the 2019 ESC Guidelines very high risk category.

CONCLUSIONS

One-fifth of this T1D cohort had a positive CAC score. The ST1RE was superior in identifying positive CAC compared to the 2019 ESC Guidelines. Further studies are required to elucidate the role of CAC in personalising CV risk-stratification and statin initiation in T1D.

The Bittersweet Beat: Diabetes Complications

In this Editorial, we are focusing on a selection of articles recently published in the Journal of Clinical Medicine dealing with relevant aspects of cardiometabolic complications of diabetes mellitus [...].

Hyperlipidemia and Cardiovascular Disease in People with Type 1 Diabetes: Review of Current Guidelines and Evidence

PURPOSE OF REVIEW

In this review, we discuss the prevalence of cardiovascular disease in people with type 1 diabetes. We outline key risk factors associated with increased cardiovascular event rates and discuss the prevalence and mechanisms underlying hyperlipidemia in people with type 1 diabetes. Finally, we summarize the evidence to support early and more aggressive lipid-lowering therapy in people with type 1 diabetes and review current guideline recommendations.

RECENT FINDINGS

Comprehensive treatment of hyperglycemia, hypertension, and hyperlipidemia reduces adverse cardiovascular outcomes in people with type 2 diabetes. In contrast, evidence to support a comparable benefit of intensive cardiovascular risk factor management in people with type 1 diabetes is lacking from prospective, randomized trials and has only been shown in registries. Therefore, current treatment guidelines extrapolate prospective clinical trial evidence obtained in people with type 2 diabetes to provide similar treatment recommendations for people with type 1 and type 2 diabetes. Evidence supports the more aggressive treatment of cardiovascular risk factors in people with type 1 diabetes, who would likely benefit from early risk stratification and comprehensive risk factor management, including aggressive lipid-lowering therapy.

Clinical and Safety Outcomes With GLP-1 Receptor Agonists and SGLT2 Inhibitors in Type 1 Diabetes: A Real-World Study

CONTEXT

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) are used off-label in the management of type 1 diabetes mellitus (T1DM) in real-world practice as adjuvant therapies to insulin. There are few real-world data regarding efficacy and safety of this practice.

OBJECTIVE

This work aimed to determine the efficacy and safety of GLP-1RAs and sodium-glucose SGLT2is in the management of T1DM in real-world practice.

METHODS

A retrospective chart review was performed of all instances of GLP-1RA and/or SGLT2i use greater than 90 days in adult patients with T1DM at a single academic center. We report the clinical and safety outcomes over the duration of use.

RESULTS

We identified 104 patients with T1DM who ever used a GLP-1RA (76 patients) or SGLT2i (39 patients) for more than 90 days. After 1 year of therapy, GLP-1RA users had statistically significant reductions in weight (90.5 kg to 85.4 kg; P < .001), glycated hemoglobin A1c (HbA1c) (7.7% to 7.3%; P = .007), and total daily dose of insulin (61.8 units to 41.9 units; P < .001). SGLT2i users had statistically significant reductions in HbA1c (7.9% to 7.3%; P < .001) and basal insulin (31.3 units to 25.6 units; P = .003). GLP-1RA users compared to SGLT2i users had greater reduction in weight (P = .027) while HbA1c reduction was comparable between the groups. Over a mean total duration of use of 29.5 months/patient for both groups, more SGLT2i users experienced diabetic ketoacidosis (DKA) (12.8% vs 3.9%). Therapy was discontinued because of adverse events 26.9% of the time for GLP-1RA users vs 27.7% for SGLT2i users.

CONCLUSION

GLP-1RA and SGLT2i use in T1DM is associated with clinically relevant benefits. DKA remains a clinical concern with SGLT2i use, requiring careful patient selection and monitoring, with the risk to benefit ratio of treatment evaluated at an individual level.

Effect of Physical Activity/Exercise on Cardiorespiratory Fitness in Children and Adolescents with Type 1 Diabetes: A Scoping Review

The most common type of diabetes among children and adolescents is type 1 diabetes mellitus (T1DM), which is associated with an increased risk of cardiovascular disease (CVD). Additionally, lower levels of cardiorespiratory fitness (CRF) are linked to an increased risk of CVD. Regular exercise is associated with a decreased risk of CVD and improved CRF. We conducted this scoping review to assess the effects of exercise on CRF in youth with T1DM. Three electronic databases (PubMed, Embase, and Cochrane Central Register of Controlled Trials) were used to search for the relevant literature. In this analysis, the PICOS method was used to select studies and was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines scoping review guidelines for the evaluation of the effects of physical activity and cardiac function; the criteria may include the type and intensity of physical activity, the duration of the intervention, peak oxygen consumption (VO2), peak minute ventilation (VE), and peak heart rate of cardiorespiratory fitness. Screening resulted in 434 records. Of these, nine articles were included in our study. These nine studies were experimental (noncontrolled trials or randomized controlled trials) (n = 7) and observational (cross-sectional) (n = 2), and could be used to evaluate the effectiveness of physical activity interventions on cardiac function. The effects of exercise on CRF in youth with T1DM vary according to the type, frequency, and intensity of the exercise. According to our review, the duration of exercise included in the studies did not meet the recommendations of the guidelines for youth with T1DM. Additionally, half of the studies revealed that exercise could optimize the lipid profile in youth with T1DM. Hence, this research is to provide an overview of the effects of physical activity and exercise on CRF, cardiovascular fitness, lipid profile, and blood pressure in youth with T1DM, as well as identified potential limitations of the existing studies. Nevertheless, the limited number of clinical studies employing exercise interventions for children and adolescents with T1DM emphasize the need for more studies in this area, and more specific modes of exercise should be developed in the future.

Type 1 diabetes: key drug targets and how they could influence future therapeutics

INTRODUCTION

Despite significant strides made in the management of T1DM, standard management is still insulin analog therapy. Some non-insulin therapies traditionally reserved for the treatment of T2DM have been explored in caring for patients with T1DM, and pancreas transplant is an option for few. However, T1DM remains a challenging disease to manage, encouraging development of novel pharmacologic agents.

AREAS COVERED

We retrieved PubMed, Cochrane Library, Scopus, Google Scholar, and ClinicalTrials.gov records to identify studies and articles focused on new pharmacologic advances to treat T1DM.

EXPERT OPINION

Recent research has focused on new targets of pharmacologic treatment of T1DM. Beta-cell preservation through immunomodulation or inhibiting inflammation hopes to delay or halt the progression of the disease. Beta cell regeneration through islet cell transplant or modification in transcription pathways aim to reverse the disease effects. Multiple other new targets such as glucagon antagonism and glucokinase activation are also in development as a potential adjunctive therapy. These new therapeutic targets offer the hope of reducing the daily burden of diabetes management with eventual insulin discontinuation for many individuals with T1DM.

Carotid ultrasonography as a strategy to optimize cardiovascular risk management in type 1 diabetes: a cohort study

BACKGROUND AND AIMS

Although cardiovascular disease (CVD) remains the leading cause of mortality in type 1 diabetes (T1D), the use of cardioprotective drugs is scarce. We aimed to evaluate the impact of carotid ultrasonography (US) on the improvement in cardiovascular risk factors (CVRFs) in T1D.

METHODS AND RESULTS

T1D patients without CVD meeting criteria for lipid treatment according to guidelines (age ≥ 40 years, nephropathy and/or ≥ 10 years of diabetes duration with ≥ 1 additional CVRFs) were included. The carotid-US group (US-G) underwent a standardized US protocol and CVRF assessment; recommendations were made according to subclinical atherosclerosis status. The control group (CG) followed usual clinical practice. Changes in CVRFs, specially statin use and LDL cholesterol levels, at 1 year were analysed. A total of 318 patients were included (51.3% female, mean age of 49.1 years and 25.5 years of diabetes duration): 211 in the US-G and 107 in the CG. Participants in the US-G had a higher baseline LDL cholesterol than controls (114 vs. 102 mg/dL; p < 0.001). Lipid-lowering treatment was modified in 38.9% in the US-G and 6.5% in the CG (p < 0.001). At 1 year, the US-G was more frequently on statins, had lower LDL cholesterol and 27% had stopped smoking (p < 0.001 for all). Changes were more pronounced in those with plaques (p < 0.001). In multivariate analyses adjusted for age, sex and other CVRFs, belonging to the US-G was independently associated with the intensification of lipid-lowering treatment (OR 10.47 [4.06-27.01]). Propensity score-matching analysis yielded similar results (OR 20.09 [7.86-51.37]).

CONCLUSION

Carotid-US is independently associated with an intensification of lipid-lowering therapy in a high-risk T1D population.

Arterial stiffness indices in children and adolescents with type 1 diabetes mellitus: A meta-analysis

AIMS

Cardiovascular disease (CVD) represents the most frequent cause of morbidity and mortality among patients with type 1 diabetes mellitus (T1DM). Our aim was to review the evidence and conduct a meta-analysis assessing measures of arterial stiffness by pulse wave velocity (PWV) and augmentation index (AIx) in children and adolescents with T1DM compared to healthy controls.

METHODS

PubMed and the Cochrane Library were searched for relevant studies published up to 10 May 2021.

RESULTS

Twenty-one studies were finally included in the meta-analysis. The T1DM group had significantly higher carotid to femoral PWV levels than that of the control group (mean difference [d]: 0.53 CI: 0.35-0.71, P < 0.00001) but with a fair heterogeneity (I 2:73%). By omitting one study with marked heterogeneity, mean difference in cfPWV remained significantly increased in the T1DM group compared to the control group (mean difference [d]: 0.37 CI: 0.27-0.48, P < 0.00001) but with improved heterogeneity (I2 = 26%). Regarding Aix, the T1DM group had a significantly higher AI@75 index than that of the control group (mean difference [d]: 0.28 CI: 0.17-0.39, P < 0.00001) and with no heterogeneity (I 2 = 8%).

CONCLUSIONS

Youths with T1DM show increased arterial stiffness, either as increased carotid-femoral pulse wave velocity or increased augmentation index, early in their course of life compared to healthy controls.

PROSPERO REGISTRATION NUMBER

CRD42021253236.

The Impact of an Elevated Uric Acid Level on the Prevalence of Coronary Artery Disease in Pancreas Transplant Candidates with Type 1 Diabetes: A Cross Sectional Study

Pancreas transplantation is considered a high-risk surgery with cardiovascular complications. Early detection of all potential cardiovascular risk factors can decrease the perioperative risk and improve the pancreas recipients' outcome. The present study aims to evaluate the association between serum uric acid (UA) levels and the prevalence of coronary artery disease (CAD) in patients eligible for pancreas transplantation. We prospectively enrolled 63 consecutive patients with type 1 diabetes (T1D) who underwent cardiological evaluation before pancreas transplantation in our center. Participants underwent clinical evaluation, laboratory assays, and coronary angiography. The median concentration of UA in patients with CAD was significantly higher than in participants without CAD (6.43 (4.93-7.26) vs. 4.41 (3.64-5.49) mg/dL, p = 0.0002). We showed the positive correlation between UA concentration and systolic blood pressure, pulse pressure (PP) and triglycerides (r = 0.271, p = 0.032; r = 0.327, p = 0.009; r = 0.354, p = 0.004, respectively). In a multivariate analysis, the concentration of UA (OR 2.044; 95% CI: 1.261-3.311, p = 0.004) was independently associated with the prevalence of CAD in pancreas transplant candidates with T1D. We demonstrated that elevated UA levels were strongly associated with the high prevalence of CAD in pancreas transplant candidates with T1D. To stratify cardiovascular risk, the measurement of the UA concentration should be considered in all T1D patients qualified for pancreas transplantation.

Dyslipidemia Among Patients With Type 1 Diabetes and Its Associated Factors in Saudi Arabia: An Analytical Cross-Sectional Study

Objectives

The present study was conducted to determine the prevalence of dyslipidemia among patients with type 1 diabetes mellitus (T1DM) and its associated factors in Saudi Arabia.

Methods

An analytical cross-sectional study was conducted to examine patients with T1DM at a tertiary care hospital in Riyadh, Saudi Arabia. The hospital’s electronic medical records (EMRs) and a telephone survey were used to collect data after obtaining institutional approval and informed consent from every patient. The inclusion criteria included age >18 years, T1DM, and follow-up at the tertiary care hospital. The data collected included age, gender, hypertension, glycosylated hemoglobin (HbA1c), body mass index (BMI), diabetes duration, total cholesterol, triglycerides (TG), low-density lipoprotein (LDL), and high-density lipoprotein (HDL).

Results

A total of 234 patients with T1DM were included in the study, which comprised 44.4% men and 55.6% women with an average age of 30.9 ± 9.7 years. Total cholesterol, TG, LDL-C, and HDL-C were 4.6 ± 1.04 mmol/L, 1.1 ± 0.60 mmol/L, 2.6 ± 0.89 mmol/L, and 1.5 ± 0.43 mmol/L, respectively. About 18.4% were hypertensive, and about 51.9% and 50% men and women had dyslipidemia, respectively. Males and HbA1c ≥ 7% showed significant associations with dyslipidemia.

Conclusion

Dyslipidemia is prevalent in patients with T1DM in Saudi Arabia, which warrants the use of solid preventive strategies to limit the risk of cardiovascular disease.

Physical Activity, Dietary Patterns, and Glycemic Management in Active Individuals with Type 1 Diabetes: An Online Survey

Individuals with type 1 diabetes (T1D) are able to balance their blood glucose levels while engaging in a wide variety of physical activities and sports. However, insulin use forces them to contend with many daily training and performance challenges involved with fine-tuning medication dosing, physical activity levels, and dietary patterns to optimize their participation and performance. The aim of this study was to ascertain which variables related to the diabetes management of physically active individuals with T1D have the greatest impact on overall blood glucose levels (reported as A1C) in a real-world setting. A total of 220 individuals with T1D completed an online survey to self-report information about their glycemic management, physical activity patterns, carbohydrate and dietary intake, use of diabetes technologies, and other variables that impact diabetes management and health. In analyzing many variables affecting glycemic management, the primary significant finding was that A1C values in lower, recommended ranges (<7%) were significantly predicted by a very-low carbohydrate intake dietary pattern, whereas the use of continuous glucose monitoring (CGM) devices had the greatest predictive ability when A1C was above recommended (≥7%). Various aspects of physical activity participation (including type, weekly time, frequency, and intensity) were not significantly associated with A1C for participants in this survey. In conclusion, when individuals with T1D are already physically active, dietary changes and more frequent monitoring of glucose may be most capable of further enhancing glycemic management.

The Role of Epidermal Growth Factor Receptor Family of Receptor Tyrosine Kinases in Mediating Diabetes-Induced Cardiovascular Complications

Diabetes mellitus is a major debilitating disease whose global incidence is progressively increasing with currently over 463 million adult sufferers and this figure will likely reach over 700 million by the year 2045. It is the complications of diabetes such as cardiovascular, renal, neuronal and ocular dysfunction that lead to increased patient morbidity and mortality. Of these, cardiovascular complications that can result in stroke and cardiomyopathies are 2- to 5-fold more likely in diabetes but the underlying mechanisms involved in their development are not fully understood. Emerging research suggests that members of the Epidermal Growth Factor Receptor (EGFR/ErbB/HER) family of tyrosine kinases can have a dual role in that they are beneficially required for normal development and physiological functioning of the cardiovascular system (CVS) as well as in salvage pathways following acute cardiac ischemia/reperfusion injury but their chronic dysregulation may also be intricately involved in mediating diabetes-induced cardiovascular pathologies. Here we review the evidence for EGFR/ErbB/HER receptors in mediating these dual roles in the CVS and also discuss their potential interplay with the Renin-Angiotensin-Aldosterone System heptapeptide, Angiotensin-(1-7), as well the arachidonic acid metabolite, 20-HETE (20-hydroxy-5, 8, 11, 14-eicosatetraenoic acid). A greater understanding of the multi-faceted roles of EGFR/ErbB/HER family of tyrosine kinases and their interplay with other key modulators of cardiovascular function could facilitate the development of novel therapeutic strategies for treating diabetes-induced cardiovascular complications.