Evaluation of cardiovascular risk in adults with type 1 diabetes: poor concordance between the 2019 ESC risk classification and 10-year cardiovascular risk prediction according to the Steno Type 1 Risk Engine

Abstract

Background Patients with type 1 diabetes (T1D) have higher mortality risk compared to the general population; this is largely due to increased rates of cardiovascular disease (CVD). As accurate CVD risk stratification is essential for an appropriate preventive strategy, we aimed to evaluate the concordance between 2019 European Society of Cardiology (ESC) CVD risk classification and the 10-year CVD risk prediction according to the Steno Type 1 Risk Engine (ST1RE) in adults with T1D. Methods A cohort of 575 adults with T1D (272F/303M, mean age 36 ± 12 years) were studied. Patients were stratified in different CVD risk categories according to ESC criteria and the 10-year CVD risk prediction was estimated with ST1RE within each category. Results Men had higher BMI, WC, SBP than women, while no difference was found in HbA1c levels between genders. According to the ESC classification, 92.5% of patients aged < 35 years and 100% of patients ≥ 35 years were at very high/high risk. Conversely, using ST1RE to predict the 10-year CVD risk within each ESC category, among patients at very high risk according to ESC, almost all (99%) had a moderate CVD risk according to ST1RE if age < 35 years; among patients aged ≥35 years, the majority (59.1%) was at moderate risk and only 12% had a predicted very high risk by ST1RE. The presence of target organ damage or three o more CV risk factors, or early onset T1D of long duration (> 20 years) alone identified few patients (< 30%) among those aged ≥35 years, who were at very high risk according to ESC, in whom this condition was confirmed by ST1RE; conversely, the coexistence of two or more of these criteria identified about half of the patients at high/very high risk also according to this predicting algorithm. When only patients aged ≥ 50 years were considered, there was greater concordance between ESC classification and ST1RE prediction, since as many as 78% of those at high/very high risk according to ESC were confirmed as such also by ST1RE. Conclusions Using ESC criteria, a large proportion (45%) of T1D patients without CVD are classified at very high CVD risk; however, among them, none of those < 35 years and only 12% of those ≥ 35 years could be confirmed at very high CVD risk by the ST1RE predicting algorithm. More studies are needed to characterize the clinical and metabolic features of T1D patients that identify those at very high CVD risk, in whom a very aggressive cardioprotective treatment would be justified.

Arterial stiffness in patients with type 1 diabetes and its comparison to cardiovascular risk evaluation tools

“…Indeed, based on these 2019 ESC criteria, a very large proportion (81.5%) of study patients were classified as very high CVD risk, which was almost 20% more than the proportion based on STENO (63%). Our data thereby show both the heterogeneity in CV risk as well as the discrepancy between the ESC criteria and STENO score as reported before [7]. Hence, there is a need for refined CV risk classification in T1D and the development of prediction models specific for this high-risk group [9,39].…”

“…According to the latest European Society of Cardiology (ESC) guidelines on diabetes, prediabetes and CVD, patients with a longer T1D duration (i.e., > 10 years) are automatically considered at highor very high risk to develop CVD [6]. However, there seems to be substantial heterogeneity in CV risk in T1D [7,8]. Therefore, it is crucial to accurately assess CV risk in patients with T1D and there is growing research interest into CV risk stratification tools [8][9][10][11].…”

Cardiovascular Disease in Type 1 Diabetes Mellitus: Epidemiology and Management of Cardiovascular Risk

“…According to ESC/EAS criteria, most T1DM patients are at high/very high risk, which implies very ambitious targets for LDL-C, more stringent blood pressure control, and the use of antiplatelet agents [ 127 ]. Recently, Tecce et al [ 130 ] evaluated the concordance between 2019 ESC/EAS CVD risk classification and 10-year CVD risk predictions, according to the Steno Type 1 Risk Engine, in 575 adults with T1DM with a mean age of 36 ± 12 years. Using ESC/EAS criteria, a large proportion (45%) of T1DM patients without CVD are classified at very high CVD risk.…”

Comparison of the effects of triglyceride variability and exposure estimate on clinical prognosis in diabetic patients

“…In particular, lipid accumulation over a long duration of time is closely related to poorer cardiovascular outcomes and all-cause mortality [ 6 – 8 ]. Along with increased serum lipid levels, presence of type 1 or type 2 diabetes mellitus is also one of the major risk factors of atherosclerotic cardiovascular disease, which is a leading cause of death in diabetic patients [ 9 , 10 ]. Therefore, presence of dyslipidemia together with diabetes mellitus may result in increased cardiovascular risk and bring poorer clinical outcomes [ 11 , 12 ].…”

“…disease, which is a leading cause of death in diabetic patients [9,10]. Therefore, presence of dyslipidemia together with diabetes mellitus may result in increased cardiovascular risk and bring poorer clinical outcomes [11,12].…”