Lipid-lowering therapies and cardiovascular risk-stratification strategies in adults with type 1 diabetes

Abstract

Purpose of reviewAtherosclerotic cardiovascular disease (ASCVD) is a leading cause of mortality in adults with type 1 diabetes (T1D). Although dyslipidaemia is a modifiable and prevalent risk factor in individuals with T1D, determining when to initiate lipid-lowering therapy for primary prevention of ASCVD can be challenging. In this article, recommendations for lipid-lowering therapy from updated clinical guidelines over the last 5 years, additional risk-stratification methods, hypertriglyceridaemia management and potential barriers to optimal care in adults with T1D are discussed. Recent findingsLow-density lipoprotein cholesterol (LDL-C) is the primary target for lipid-lowering. However, international guidelines recommend differing approaches to ASCVD risk-stratification, lipid-lowering, and LDL-C goals in individuals with diabetes, predominantly reflecting evidence from studies in type 2 diabetes. Despite guideline recommendations, several studies have demonstrated that statins are underused, and LDL-C goals are not attained by many individuals with T1D. Additional risk-stratification methods including T1D-specific ASCVD risk calculators, coronary artery calcium scoring, and lipoprotein(a) may provide additional information to define when to initiate lipid-lowering therapy. SummaryClinical trial evidence for lipid-lowering therapies in T1D is lacking, and further studies are needed to inform best practice. Optimization and harmonization of ASCVD risk-stratification and lipid management in individuals with T1D is required.

Cardiovascular risk stratification in type 1 diabetes: do risk calculators and guidelines align?

“…Cardiovascular disease (CVD) remains a leading cause of premature mortality in type 1 diabetes (T1D). However, CVD risk in T1D is heterogenous, and the optimal methods of CVD risk‐stratification in this unique group remain uncertain 1 . Although glycaemic control reduces CVD risk in T1D, significant residual risk remains 2 .…”

“…In T1D patients without CVD and not receiving statins, QRISK3‐2018 and Australian CVD Check classified more patients at lower risk compared with the ST1RE, whilst the ESC guidelines classified more patients at higher risk, which may lead to more intensive risk factor modification 7 . Importantly, primary prevention calculators for the general population do not include diabetes duration, diabetes type, glycaemic control and albuminuria, factors considered by ST1RE 1 . The ST1RE predicts subclinical atherosclerosis, as well as CVD events in T1D, but has not been validated in an Australian cohort 8,9 .…”

“…7 Importantly, primary prevention calculators for the general population do not include diabetes duration, diabetes type, glycaemic control and albuminuria, factors considered by ST1RE. 1 The ST1RE predicts subclinical atherosclerosis, as well as CVD events in T1D, but has not been validated in an Australian cohort. 8,9 Other biomarkers/imaging for atherosclerosis, such as coronary artery calcium score, were not available for our study.…”

“…However, CVD risk in T1D is heterogenous, and the optimal methods of CVD risk-stratification in this unique group remain uncertain. 1 Although glycaemic control reduces CVD risk in T1D, significant residual risk remains. 2 This highlights the importance of early CVD risk stratification and risk-factor modification.…”