CVD Screening and Treatment
Much of the existing data on the risk of CVD in individuals with diabetes is based on people with type 2 diabetes who often have additional CVD risk factors, such as metabolic syndrome, hypertension, and dyslipidemia. How much is applicable to people with type 1 diabetes is unknown. However, people with type 1 diabetes are at increased risk for CVD, particularly those with additional risk factors.
In type 1 diabetes, standard risk factors apply, such as hyperlipidemia, hypertension, age, family history, smoking, weight, and presence of albuminuria. As such, these should be considered when determining the need for evaluation and treatment for CVD. However, even in the absence of classic risk factors, there may be high CVD risk. An adult with childhood-onset type 1 diabetes of 20-year duration has a substantially increased risk of coronary artery disease of 1% per year, thus meriting high-intensity statin therapy according to the new joint American College of Cardiology/American Heart Association guidelines (≥7.5% 10-year risk). In some cases, measurement of coronary artery calcification may be a helpful method for determining CVD risk. Here, as with all management issues for people with type 1 diabetes, providers need to individualize assessment and treatment options.
With regard to treatment, statin therapy is the preferred treatment for lipid lowering/CVD risk reduction. The Heart Protection Study (HPS) did include type 1 diabetic participants who appeared to experience the same degree of benefit from statins as others in the study, though the finding was not statistically significant due to low numbers. Unfortunately, there are no blood pressure intervention trials with CVD end points in type 1 diabetes and only one LDL cholesterol–lowering trial. Statin and aspirin therapy (if not contraindicated) should be considered and used as is individually indicated.
Therapy for those under age 40 years with less than a 20-year diabetes duration (or over age 75 years) should be considered on an individual basis, though, depending on overall risk, an LDL cholesterol <100 mg/dL has been suggested as an appropriate goal with statin intervention for those with LDL cholesterol levels of 130–160 mg/dL. (E)
Individuals with type 1 diabetes aged 40–75 years may benefit from moderate-to-intensive statin therapy with consideration of diabetes duration and CVD risk factors. If 10-year risk is estimated to be ≥7.5%, then intensive statin therapy should be considered. (B)
Diabetes Care. 2014;37(7):2034-2054. © 2014 American Diabetes Association, Inc.