Substantial and steady reductions in the rates of atherosclerotic cardiovascular disease (ASCVD) in patients with type 2 diabetes (T2D) and in the general population without diabetes were seen over the last two decades, but reductions in heart failure (HF) in T2D plateaued in more recent time periods, according to results of a national cohort study conducted in Sweden and published May 8 in Circulation. Compared with the general population, the excess risk of ASCVD and HF remained higher in patients with T2D.

Naveed Sattar, MD, et al., investigated trends in cardiometabolic risk and ASCVD events from 2001-2019 using data from 679,072 patients from the Swedish National Diabetes Registry and 2,643,800 matched controls without diabetes.

Results showed that in patients with T2D the incidence per 10,000 person-years in 2001 and in 2019 was 73.9 vs. 41.0 for acute myocardial infarction); 205.1 vs. 80.2 for coronary artery disease (CAD); 83.9 vs. 46.2 for cerebrovascular disease; and 98.3 vs. 75.9 for HF. Around 2013, the incidence of HF plateaued.

Cardiometabolic risk factors independently associated with outcomes in T2D patients were glycated hemoglobin, systolic blood pressure, estimated glomerular filtration rate and lipids. The authors note that body mass index (BMI) alone potentially explained >30% of HF risk in T2D.

Compared with controls, in patients with T2D whose risk factors were controlled below target levels, there was no increased cardiovascular risk – with the exception of HF where there was a 50% increase in risk even when all risk factors were below targets.

There was a stepwise increase in the risk of CAD and cerebrovascular disease for each risk factor not within target. The most important risk factor to predict incident atherosclerotic events was glycated hemoglobin and to predict incident HF was BMI.

The authors write that the decrease in the incidence of ASCVD seen in this study is likely due to the developments in management of patients with T2D, newer and more stringent risk factor targets, better risk factor control by both lifestyle intervention and pharmacological therapy, and new therapies including LDL-C lowering, antihyperglycemics and antithrombotics. Regarding the plateauing in HF, they note if the trend continues, it will surpass CAD as the most common complication in patients with T2D.

In an accompanying editorial comment, Bige Ozkan, MD, ScM, and Chiadi E. Ndumele, MD, PhD, write that this study illustrates the “need to comprehensively control cardiometabolic risk factors, including overweight and obesity with both lifestyle and pharmacological therapies” and that the authors should be applauded “for their important work demonstrating the trends in cardiovascular outcomes in a large, population-based cohort of individuals with diabetes.”

Clinical Topics: Dyslipidemia, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Lipid Metabolism

Keywords: Lipids, Cerebrovascular Disorders, Myocardial Infarction, Cardiometabolic Risk Factors, Glomerular Filtration Rate, Coronary Artery Disease, Fibrinolytic Agents, Cardiovascular Diseases, Diabetes Mellitus, Type 2, Hypoglycemic Agents

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