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Development of Heart Disease in Young Adults with Type 1 Diabetes — ADA 2019

Jul 2, 2019
 
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Maya Rudolph, Florida A&M University, College of Pharmacy & Pharmaceutical Sciences, PharmD Candidate

Could older recommendations of maintaining blood pressure of 140/90 mmHg be misleading for reducing heart disease in young adults with type 1 diabetes? 

Young adults with type 1 diabetes have an increased risk of mortality related to cardiovascular disease. High blood pressure and high glucose levels pose a threat for young adults with type 1 diabetes developing heart disease. The findings that blood pressure levels greater or equal to 120/80mmHg are associated with high risk of heart disease was presented at the American Diabetes Association (ADA’s) 79th Scientific Sessions in San Francisco. The evidence presented was taken from the study, “Optimal Blood Pressure Goals for Cardiovascular Health in Individuals with Type 1 Diabetes.”

 The Pittsburgh Epidemiology of Diabetes Complications (EDC) Study enrolled 605 patients who were diagnosed with type 1 diabetes at the age of 17 or younger. Within one-year of the diagnosis, patients had to be seen at the Children’s Hospital of Pittsburgh between 1950 and 1980. The patients with no known coronary artery disease (CAD) were followed for 25 years. The primary goal of the study was to determine the optimal blood pressure goals in younger patients with childhood-onset type 1 diabetes to minimize the risk of coronary artery disease.

Time-weighted blood pressure measurements were used to imitate long term exposure to blood pressure. A dose-gradient analysis was used between time-weighted systolic and diastolic blood pressures, along with mean arterial pressure and CAD risk. Cut-points of time weighted blood pressures were summarized by sensitivity, specificity, and the area under the curve. For lower CAD risk, the target levels for systolic and diastolic blood pressure were 120 and 80 mmHg, respectively and the mean arterial pressure was 90 mmHg. Patients with a blood pressure ≥ 120/80 mmHg had a two-fold increased risk of developing CAD, compared to patients with a blood pressure <120/80 mmHg (HR: 1.9; 95% CI 1.4- 2.6). Patients were divided into four categories by time-weighted blood pressure: (< or ≥ 120/80 mmHg) and time-weighted HbA1c (< or ≥ 8%), compared to patients meeting targets for both blood pressure (<120/80 mmHg) and HbA1c (<8%). The high blood pressure only group and the high HbA1c only group carried a similar risk of CAD; HR= 2.0 (95% CI 1.1-3.9) and HR= 1.6 (95% CI 0.97- 2.8), respectively.

Despite the current recommendation for optimal blood pressure as 140/90 mmHg, the findings from this study support cardiovascular risk reduction with maintaining a blood pressure of 120/80 mmHg in younger patients with type 1 diabetes. In a 2018, cohort Swedish National Diabetes Study, researchers found that age onset is an important determinant of survival in connection to cardiovascular risk and mortality in younger patients with type 1 diabetes. The Swedish study suggested that cardio-protection be a focus point warranted for these patients.

During the ADA’s Scientific Session, lead study author Jingchuan Guo, MD, PhD, stated how intrigued researchers were by the findings suggesting that blood pressure and blood glucose are both important in minimizing cardiovascular risks. According to Dr. Guo, the initial treatment focus in patients with type 1 diabetes should be glucose control when HbA1c is very high, but when these levels become normal, controlling blood pressure is critically important.

 Practice Pearls:

  •  Improving long term outcomes and reducing mortality in younger patients with type 1 diabetes, lowering blood pressure and controlling blood glucose levels are important.
  • Lowering blood pressure may decrease cardiovascular risk and provide optimal glucose levels in younger patients with type 1 diabetes.
  • This study supports the evidence of maintaining a blood pressure of 120/80 mmHG to reduce the risk of cardiovascular threat in younger patients.

References:

ADA 2019: Hypertension and High Glucose Levels Pose Comparable CV Risk for Young Adults With Type 1 Diabetes.” PracticeUpdate, www.practiceupdate.com/c/85194/32/8/?elsca1=emc_conf_ADA2019Post-1&elsca2=email&elsca3=practiceupdate_diabetes&elsca4=201952_ADA2019Post-1&elsca5=conference&rid=OTE0MTIxOTE4NTkS1&lid=10332481.

Guo, Jingchuan. High Blood Pressure and Elevated Glucose Levels Present Comparable Risk for Young Adults with Type 1 Diabetes to Develop Heart Disease. Presented at: American Diabetes Association 79th Scientific Sessions; June 7-11, 2019; San Francisco.

 

Maya Rudolph, Florida A&M University, College of Pharmacy & Pharmaceutical Sciences, PharmD Candidate