In T1DM without CVD, the LIFE-T1D model predicted lifetime risk for CVD and non-CVD mortality
The most important implication of this new model for predicting cardiovascular disease (CVD) risk among patients with type 1 diabetes (T1DM) may be that it will motivate clinicians to initiate statin therapy in younger patients, an ACP Journal Club commentary said.
A recent study developed and validated a model for predicting risk of cardiovascular disease (CVD) among patients with type 1 diabetes (T1DM), over the following 10 years and their entire lifetimes. Factors in the model included age at diabetes onset, smoking status, body mass index, systolic blood pressure, glycated hemoglobin level, estimated glomerular filtration rate (eGFR), non-high-density lipoprotein cholesterol, albuminuria and retinopathy. Internal validation found the model to have a c-statistic of 0.85, and c-statistics were 0.77 and 0.73 in external validations.
The study was published by Diabetes, Obesity and Metabolism on March 8. The following commentary by Michael Tanner, MD, FACP, was published in the ACP Journal Club section of Annals of Internal Medicine on July 2.
The LIFE-T1D CV risk prediction model by Helmink and colleagues was derived from 39,756 patients with T1DM in the Swedish National Diabetes Registry. Median age was 28 years at baseline assessment and 14 years at diagnosis.
Although patients aged <40 years had a low median 10-year risk for major adverse CV events (1%), their lifetime risk was high (69%). Indeed, patients with T1DM begin to accrue atherosclerotic burden early in life, so the metric of 10-year risk can be falsely reassuring; lifetime risk is a more meaningful metric.
In T1DM, standard of care for treating hyperglycemia is insulin, and standard of care for treating hypertension and albuminuria is angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. The most important treatment implication of the LIFE-T1D model may be wider adoption of the 2022 American College of Cardiology guidelines, which state that it may be reasonable to initiate statin therapy for adults aged 20 to 39 years with long-duration diabetes and evidence of vascular harm including urinary albumin–creatinine ratio >30 mg/g, eGFR <60 mL/min, retinopathy, neuropathy, or ankle–brachial index <0.9.
An exciting new approach to reducing CV events in T1DM is to delay the onset of disease. The T-cell deactivator teplizumab preserves β-cell function and was approved by the U.S. Food and Drug Administration in November 2022 to delay the onset of stage 3 (clinical) T1DM in adults and children aged >8 years who are at stage 2 (preclinical). Teplizumab is the first disease-modifying therapy in T1DM, with others likely to come.
Delaying the onset of clinical disease and beginning statin therapy before the age of 40 years can only help to lower lifetime CVD risk in T1DM.