Risk Factors for Cardiovascular Disease (CVD) in Adults With Type 1 Diabetes

Findings From Prospective Real-Life T1D Exchange Registry

Viral N Shah; Ryan Bailey; Mengdi Wu; Nicole C. Foster; Rodica Pop-Busui; Michelle Katz; Jill Crandall; Fida Bacha; Kristen Nadeau; Ingrid Libman; Paul Hiers; Kara Mizokami-Stout; Linda A. DiMeglio; Jennifer Sherr; Richard Pratley; Shivani Agarwal; Janet Snell-Bergeon; Eda Cengiz; Sarit Polsky; Sanjeev N. Mehta


J Clin Endocrinol Metab. 2020;105(5) 

In This Article

Abstract and Introduction


Context: Cardiovascular disease (CVD) is a major cause of mortality in adults with type 1 diabetes.

Objective: We prospectively evaluated CVD risk factors in a large, contemporary cohort of adults with type 1 diabetes living in the United States.

Design: Observational study of CVD and CVD risk factors over a median of 5.3 years.

Setting: The T1D Exchange clinic network.

Patients: Adults (age ≥ 18 years) with type 1 diabetes and without known CVD diagnosed before or at enrollment.

Main Outcome Measure: Associations between CVD risk factors and incident CVD were assessed by multivariable logistic regression.

Results: The study included 8,727 participants (53% female, 88% non-Hispanic white, median age 33 years [interquartile ratio {IQR} = 21, 48], type 1 diabetes duration 16 years [IQR = 9, 26]). At enrollment, median HbA1c was 7.6% (66 mmol/mol) (IQR = 6.9 [52], 8.6 [70]), 33% used a statin, and 37% used blood pressure medication. Over a mean follow-up of 4.6 years, 325 (3.7%) participants developed incident CVD. Ischemic heart disease was the most common CVD event. Increasing age, body mass index, HbA1c, presence of hypertension and dyslipidemia, increasing duration of diabetes, and diabetic nephropathy were associated with increased risk for CVD. There were no significant gender differences in CVD risk.

Conclusion: HbA1c, hypertension, dyslipidemia and diabetic nephropathy are important risk factors for CVD in adults with type 1 diabetes. A longer follow-up is likely required to assess the impact of other traditional CVD risk factors on incident CVD in the current era.


Despite advances in diabetes care and increased life expectancy, adults with type 1 diabetes (T1D) have a 10-fold increase in cardiovascular disease (CVD) risk in addition to earlier onset of CVD and a two- to four-fold increased death rate attributed to CVD compared with the general population.[1–3]

The Diabetes Control and Complications Trial (DCCT), the Epidemiology of Diabetes Interventions and Complications (EDIC), and the Pittsburgh Epidemiology of Diabetes Complications (EDC) have contributed much to the current understanding of CVD risk in T1D.[1,4–7] Glycemic control, diabetes duration, and traditional CVD risk factors have been associated with CVD risk in T1D.[4,8,9] Intensive diabetes management focused on improved long-term glycemic control reduced the incidence of CVD by 30%.[4,5,7] In addition, studies have consistently reported nephropathy as an independent CVD risk factor in adults with T1D.[10–12] Population-based studies using national registries from the United Kingdom and Sweden demonstrated similar findings to the DCCT/EDIC and EDC studies.[3,13,14]

Over the past decade, there has been remarkable improvement in diabetes care, increased adoption of advanced diabetes technologies such as insulin pumps and continuous glucose monitors,[15] and greater use of angiotensin-converting enzyme inhibitors and statins. The impact of these advances in T1D care on CVD outcomes warrants further investigation. We evaluated the incidence and factors associated with CVD in adults with T1D participating in the T1D Exchange Clinic Network Registry, the largest registry of adults with T1D in the United States.