Practice Update: Diabetes

EDITOR’S PICKS 6

Glycemic Control Reduces Risk of Coronary Events in MenWith Type 1 Diabetes Heart (British Cardiac Society)

This excess risk increased with younger age, female sex, worse glycae- mic control and severity of renal complications. The adjusted HR in men with T1D with updated mean haemoglobin A1c (HbA1c) <6.9% (52 mmol/ mol) and normoalbuminuria was 1.30 (95% CI 0.90 to 1.88) and in women 3.16 (95% CI 2.14 to 4.65). HRs increased to 10.7 (95% CI 8.0 to 14.3) and 31.8 (95% CI 23.6 to 42.8) in men and women, respectively, with HbA1c >9.7%and renal complications. CONCLUSIONS The excess risk of AMI in T1D is substantially lower with good glycaemic control, absence of renal complications and men compared with women. In women, the excess risk of AMI or CHD death persists even among patients with good glycaemic control and no renal complications. Glycaemic control and excess risk of major coronary events in persons with type 1 diabetes. Heart 2017 Jul 14;[EPub Ahead of Print], V Matule- viciene-Anängen, A Rosengren, AM Svensson, et al.

Take-home message • This Swedish, matched control cohort study evaluated the association between major coronary events and glycemic control and renal complications in patients with type 1 dia- betes. The results revealed a significantly higher incidence of cardiac events and death in patients with type 1 diabetes, particularly in women and in those with poor glycemic con- trol and more severe renal complications. • The authors concluded that, although glycemic control and improved renal function can reduce cardiac event risk in men with type 1 diabetes, women with type 1 diabetes remain at higher risk for cardiac events despite glycemic control and renal function. Abstract OBJECTIVE The excess risk of major coronary events (acute myocardial infarction (AMI) or death from coronary heart disease (CHD)) in individ- uals with type 1 diabetes (T1D) in relation to glycaemic control and renal complications is not known. METHODS Individuals with T1D in the Swedish National Diabetes Registry after 1 January 1998, without a previous MI (n=33170) and 164698 controls matched on age, sex and county were followed with respect to non-fatal AMI or death from CHD. Data were censored at death due to any cause until 31 December 2011. RESULTS During median follow-up of 8.3 and 8.9 years for individuals with T1D and controls, respectively, 1500 (4.5%) and 1925 (1.2%), experienced non-fatal AMI or died from CHD, adjusted HR 4.07 (95% CI 3.79 to 4.36).

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COMMENT By Robert H Eckel MD W ell known for decades is the increased risk of major coro- nary heart disease (CHD) events and related mortality in patients with type 1 diabetes (T1DM) and the added risk in patients with renal disease. Examining acute myocardial infarction (AMI) and CHD death as the specific manifestations of CHD, the paper by Matulevicien-Anängen et al is the most recent example of obser- vational data from the Swedish National Diabetes Register (NDR) of what factors contribute to risk for AMI/CHD death in patients with T1DM. In this report, hazard ratios (HR) for AMI/ CHD death were assessed in 33,170 T1DM patients and 164,698 controls, well matched for age and gender, for up to 13 years (median, 8.3 and 8.9 years,

respectively) and adjusted for multiple variables except hypertension and smok- ing (model 3). Age-dependent AMI/CHD death was approximately four times more common in T1DM than in controls, with HRs similar in T1DMmen and women; however, the marked increase in HR for women with T1DM relates to the much lower inci- dence in control women. Moreover, rates increased in relationship to levels of gly- cemia (HbA1c ≤6.9% in the 1st quintile to ≥9.7% in the 5th quintile), proteinuria, and estimated glomerular filtration rate. Thus, what is new here? Unfortunately, not much. First, how generalizable are these data, and the relationship of proteinuria and renal dysfunction to cardiovascular disease events in T1DM is well recog- nized, as is the importance of glycemia to macrovascular complications, especially

in this cohort. Although the importance of the trend in glycemia to events is con- vincing, a question arises as to whether this increased slope begins at levels of HbA1c >6.9% or >7.8%, particularly for women; and data for hypoglycemia were not included. Overall, this matter becomes quite relevant for clinical practice.

Dr Eckel is a Distinguished Alumnus of the University of Cincinnati College of Medicine and the Charles A Boettcher II Endowed Chair in Atherosclerosis, and Professor of Medicine, Division of Endocrinology,

Metabolism and Diabetes and the Division of Cardiology, and Professor of Physiology and Biophysics, University of Colorado School of Medicine Anschutz Medical Campus.

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