Search

Supplemental Digital Content is available in the text., Background: Individuals with type 1 diabetes mellitus (T1DM) have a high risk of cardiovascular complications, but it is unknown to what extent fulfilling all cardiovascular treatment goals is associated with residual risk of mortality and cardiovascular outcomes in those with T1DM compared with the general population. Methods: We included all patients ≥18 years of age with T1DM who were registered in the Swedish National Diabetes Register from January 1, 1998, through December 31, 2014, a total of 33 333 patients, each matched for age and sex with 5 controls without diabetes mellitus randomly selected from the population. Patients with T1DM were categorized according to number of risk factors not at target: glycohemoglobin, blood pressure, albuminuria, smoking, and low-density lipoprotein cholesterol. Risk of all-cause mortality, acute myocardial infarction, heart failure hospitalization, and stroke was examined in relation to the number of risk factors at target. Results: The mean follow-up was 10.4 years in the diabetes group. Overall, 2074 of 33 333 patients with diabetes mellitus and 4141 of 166 529 controls died. Risk for all outcomes increased stepwise for each additional risk factor not at target. Adjusted hazard ratios for patients achieving all risk factor targets compared with controls were 1.31 (95% confidence interval [CI], 0.93–1.85) for all-cause mortality, 1.82 (95% CI, 1.15–2.88) for acute myocardial infarction, 1.97 (95% CI, 1.04–3.73) for heart failure hospitalization, and 1.17 (95% CI, 0.51–2.68) for stroke. The hazard ratio for patients versus controls with none of the risk factors meeting target was 7.33 (95% CI, 5.08–10.57) for all-cause mortality, 12.34 (95% CI, 7.91–19.48) for acute myocardial infarction, 15.09 (95% CI, 9.87–23.09) for heart failure hospitalization, and 12.02 (95% CI, 7.66–18.85) for stroke. Conclusions: A steep-graded association exists between decreasing number of cardiovascular risk factors at target and major adverse cardiovascular outcomes among patients with T1DM. However, risks for all outcomes were numerically higher for patients with T1DM compared with controls, even when all risk factors were at target, with risk for acute myocardial infarction and heart failure hospitalization statistically significantly higher.

Background: Long-term trends of cardiovascular complications and death among patients with diabetes have not been studied extensively. In addition, we aimed to examine the effect of multifactorial risk factor control, as well as optimal levels- and relative importance of cardiovascular risk factors, in patients with type 1 diabetes and type 2 diabetes. The analyses for patients with diabetes were compared to the general population. Method: We used data from the National Diabetes Register along with other Swedish health registries and applied different statistical methods such as survival analysis and different machine learning models to study our research questions. We have focused on the following outcomes: all-cause mortality, acute myocardial infarction, coronary heart disease, cardiovascular disease, stroke and heart failure. Results: During the period 1998-2014, patients with type 1 diabetes experienced approximately 40% greater relative risk reduction for cardiovascular complications, compared to matched controls, while patients with type 2 diabetes experienced roughly 20% greater risk reduction than their matched controls. A paradoxical finding was the lower relative risk reduction of fatal outcomes in patients with diabetes. Nevertheless, death and complications have decreased substantially during the last two decades. Multifactorial risk factor control is associated with significant risk reduction for patients with diabetes. Still, patients with type 1 diabetes display 82% and 97% elevated risk for myocardial infarction and heart failure, respectively. For type 2 diabetes, we observed marginally increased risk of death and cardiovascular complications in patients with all risk factor at target level. Moreover, there is a monotone relationship between number of risk factor at target level and excess risk of outcomes in patients with diabetes. Patients with type 2 diabetes and all risk factors at target level had 16% lower relative risk for myocardial infarction, compared to the general population. The most important risk factors for cardiovascular complications were glycated hemoglobin, physical activity level, systolic blood pressure, low-density lipoprotein cholesterol, albuminuria, as well as risk factors that in some form denote exposure time to the disease (e.g. age, duration of diabetes and age at onset of disease). Lower levels for glycated hemoglobin, systolic blood pressure and low-density lipoprotein cholesterol is associated with reduced risk for cardiovascular complications, compared to matched controls. The relative importance analyses suggest that risk factors contribute differently between outcomes and type of diabetes. Conclusion: Morbidity and mortality have decreased significantly among individuals with diabetes. Multifactorial risk factor control is associated with significant risk reduction and could perhaps even eliminate the excess risk for cardiovascular disease. Lower levels for selected risk factors than recommended target levels is associated with lower risk for complications. Heart failure is an emerging diabetes-related complication and young individuals with diabetes are at the highest risk of complications.

BACKGROUND: We compared individuals with type 1 diabetes (T1D) to matched controls in order to examine how age at diagnosis of T1D relates to excess mortality and cardiovascular (CV) risk. METHODS: We studied 27,195 persons with T1D in the Swedish National Diabetes Registry, and 135,178 matched controls from the general population. Using Cox regression, and with adjustment for diabetes duration, we estimated excess risk of all-cause mortality, CV mortality, non-CV mortality, acute myocardial infarction (AMI), stroke, CVD (AMI and stroke), coronary heart disease (CHD), heart failure (HF) and atrial fibrillation (AF). Individuals with T1D were categorized into five groups, according to age at diagnosis: 0–9, 10–14, 15–19, 20–24 and 25–30 years. FINDINGS: A total of 27,195 persons with T1D and 135,178 controls were included; 924 persons with T1D and 1,405 controls died during follow-up, of which median was 10 years. Patients who developed T1D at 0–10 years of age displayed hazard ratios (95% CI) of 4.11 (3.24–5.22) for death, 7.38 (3.65–14.94) for CV death, 11.44 (7.95–16.44) for CVD, 30.50 (19.98–46.57) for CHD, 30.95 (17.59–54.45) for AMI, 6.45 (4.04–10.31) for stroke, 12.90 (7.30–22.51) for HF and 1.17 (0.62–2.20) for AF. Corresponding figures for those who developed T1D in the age-range 26–30 were 2.83 (2.38–3.37) for death, 3.64 (2.34–5.66) for CV death, 3.85 (3.05–4.87) for CVD, 6.08 (4.71–7.84) for CHD, 5.77 (4.08–8.16) for AMI, 3.22 (2.35–4.42) for stroke and 5.07 (3.55–7.22) for HF; hence excess risk differed up to 5-fold across the diagnosis age. The highest overall incidence rate, noted for all-cause mortality, was 1.9 (95% CI 1.71 to 2.11) per 100.000 person-years for patients with T1D. Developing T1D before 10 years of age resulted in a loss of 17.7 and 14.2 life years for women and men, respectively, whereas years lost were 10.1 and 9.4 in those diagnosed between 26-30 years of age. INTERPRETATION: Age at onset of type 1 diabetes is an important determinant of survival, as well as all cardiovascular outcomes, with highest excess risk in females. Greater focus on cardioprotection maybe warranted in those with early onset T1D. FUNDING: Swedish Heart and Lung Foundation