Twenty Years of Cardiovascular Complications and Risk Factors in Patients With Type 2 Diabetes: A Nationwide Swedish Cohort Study

Abstract

BACKGROUND: The goal of this work was to investigate trends (2001–2019) for cardiovascular events and cardiometabolic risk factor levels in individuals with type 2 diabetes (T2D) and matched control subjects. METHODS: This study included 679 072 individuals with T2D from the Swedish National Diabetes Register and 2 643 800 matched control subjects. Incident outcomes comprised coronary artery disease, acute myocardial infarction, cerebrovascular disease, and heart failure (HF). Trends in time to first event for each outcome were analyzed with Cox regression and standardized incidence rates. In the group with T2D, Cox regression was also used to assess risk factor levels beyond target and outcomes, as well as the relative importance of each risk factor to each model. RESULTS: Among individuals with T2D, incidence rates per 10 000 person-years in 2001 and 2019 were as follows: acute myocardial infarction, 73.9 (95% CI, 65.4–86.8) and 41.0 (95% CI, 39.5–42.6); coronary artery disease, 205.1 (95% CI, 186.8–227.5) and 80.2 (95% CI, 78.2–82.3); cerebrovascular disease, 83.9 (95% CI, 73.6–98.5) and 46.2 (95% CI, 44.9–47.6); and HF, 98.3 (95% CI, 89.4–112.0) and 75.9 (95% CI, 74.4–77.5). The incidence for HF plateaued around 2013, a trend that then persisted. In individuals with T2D, glycated hemoglobin, systolic blood pressure, estimated glomerular filtration rate, and lipids were independently associated with outcomes. Body mass index alone potentially explained >30% of HF risk in T2D. For those with T2D with no risk factor beyond target, there was no excess cardiovascular risk compared with control subjects except for HF, with increased hazard with T2D even when no risk factor was above target (hazard ratio, 1.50 [95% CI, 1.35–1.67]). Risk for coronary artery disease and cerebrovascular disease increased in a stepwise fashion for each risk factor not within target. Glycated hemoglobin was most prognostically important for incident atherosclerotic events, as was body mass index for incident of HF. CONCLUSIONS: Risk and rates for atherosclerotic complications and HF are generally decreasing among individuals with T2D, although HF incidence has notably plateaued in recent years. Modifiable risk factors within target levels were associated with lower risks for outcomes. This was particularly notable for systolic blood pressure and glycated hemoglobin for atherosclerotic outcomes and body mass index for heart failure.

Addressing Cardiovascular Risk in Diabetes: It’s More Than the Sugar

“…with behavior change and pharmacological therapy as needed to achieve control of glycemia, blood pressure (BP), and cholesterol, compared with conventional therapy, resulted in a 59% reduction in cardiovascular events, a 57% reduction in cardiovascular death, and a 46% reduction in all-cause death. 6 The current study by Sattar et al 3 further highlights the importance of multifactorial risk factor control for cardiovascular outcomes in diabetes. Individuals who met target levels of hemoglobin A1c, systolic BP, lowdensity lipoprotein cholesterol, and estimated glomerular filtration rate and were nonsmokers had lower risks of ASCVD, with hazards that were comparable to or even lower than those of the control group without diabetes.…”

“…Individuals who met target levels of hemoglobin A1c, systolic BP, low-density lipoprotein cholesterol, and estimated glomerular filtration rate and were nonsmokers had lower risks of ASCVD, with hazards that were comparable to or even lower than those of the control group without diabetes. The favorable ASCVD trends described by Sattar et al 3 track closely with the substantial improvement in control of several cardiometabolic risk factors observed among individuals with diabetes over the past 2 decades. 7 During that time frame, data from the United States demonstrate that the proportion of adults with diabetes achieving lipid control rose from 25% to 56%, and BP control rose from 39% to 48%, both correlating with the increased use of pharmacological therapies.…”

“…In this issue of Circulation , Sattar et al 3 analyzed ≈680 000 patients with diabetes in the Swedish National Diabetes Register and ≈2.6 million age-, sex-, and county-matched controls to examine patterns in the incidence rates of multiple cardiovascular outcomes (ie, coronary artery disease, myocardial infarction, cerebrovascular disease, and HF) among persons with diabetes over the past 2 decades. Between 2001 and 2019, there was a continuous decline in rates of atherosclerotic cardiovascular disease (ASCVD) events among individuals with diabetes.…”

“…Although improved glycemic, lipid, and BP control, as well as lower rates of smoking, have likely played a substantial role in progressive declines in rates of ASCVD, the historic obesity epidemic persists and has begun to shift trends for HF in diabetes, with HF poised to become the leading cardiovascular complication in diabetes. The analysis by Sattar et al 3 clearly demonstrates that in diabetes, a glycemic focus alone is not sufficient. There is a need to comprehensively control cardiometabolic risk factors, including overweight and obesity with both lifestyle and pharmacological therapies; to address social determinants of health that are closely linked to diabetes and its complications; and to develop and apply coordinated, interdisciplinary approaches to support optimal cardiovascular risk reduction for patients with diabetes and multiple comorbidities.…”

Novel Prediction Equations for Absolute Risk Assessment of Total Cardiovascular Disease Incorporating Cardiovascular-Kidney-Metabolic Health: A Scientific Statement From the American Heart Association

“…In particular, HF is the leading cardiovascular manifestation among individuals with CKD. 127 Among individuals with diabetes, residual or excess risk for HF persists even when key risk factors are controlled (glycemia, blood pressure, cholesterol, albuminuria, and tobacco avoidance). 2…”