Diabetes Unit, Endocrinology and Nutrition Department, Hospital Clínic, Barcelona, Spain.
Diabetes Unit, Endocrinology and Nutrition Department, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Barcelona, Spain.
Diabetes Care. 2022 Oct 1;45(10):2412-2421. doi: 10.2337/dc22-0118.
To evaluate the concordance between the 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD (ESC/EASD-2019) and the Steno T1 Risk Engine (Steno-Risk) cardiovascular risk scales for individuals with type 1 diabetes (T1D) without cardiovascular disease (CVD) and to analyze the relationships of their use with identification of preclinical atherosclerosis.
We consecutively selected patients with T1D, without CVD, age ≥40 years, with nephropathy, and/or with ≥10 years of T1D evolution with another risk factor. The presence of plaque at different carotid segments was determined by ultrasonography. Cardiovascular risk was estimated in accord with ESC/EASD-2019 risk groups (moderate/high/very high) and the Steno-Risk (<10%, low; 10-20%, moderate; ≥20%, high), as T1D-specific scores. In an exploratory analysis, we also evaluated the non-T1D-specific 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk (ACC/AHA-2013) pooled cohort equation for individuals between 40 and 79 years of age.
We included 501 patients (53% men, mean age 48.8 years, median T1D duration 26.5 years, 41.3% harboring plaques). Concordance between T1D-specific scales was poor (κ = 0.19). A stepped increase in the presence of plaques according to Steno-Risk category was seen (18.4%, 38.2%, and 64.1%, for low, moderate, and high risk, respectively; P for trend <0.001), with no differences according to ESC/EASD-2019 (P = 0.130). Steno-Risk identified individuals with plaques, unlike ESC/EASD-2019 (area under the curve [AUC] 0.691, P < 0.001, vs. AUC 0.538, P = 0.149). Finally, in polynomial regression models (with adjustment for lipid parameters and cardioprotective treatment), irrespective of the ESC/EASD-2019 category, high risk by Steno-Risk was directly associated with atherosclerosis (in moderate/high-risk by ESC/EASD-2019 odds ratio 2.91 [95% CI 1.27-6.72] and 4.94 [2.35-10.40] for the presence of plaque and two or more plaques). Similar results were obtained with discordant higher Steno-Risk versus ACC/AHA-2013 (P < 0.001).
Among T1D patients undergoing primary prevention, use of Steno-Risk seems to result in better recognition of individuals with atherosclerosis in comparison with ESC/EASD-2019. Notwithstanding, carotid ultrasound could improve the categorization of cardiovascular risk.
评估 2019 年 ESC 与 EASD 合作制定的关于糖尿病、糖尿病前期和心血管疾病的指南（ESC/EASD-2019）与 Steno T1 风险引擎（Steno-Risk）心血管风险量表在无心血管疾病（CVD）的 1 型糖尿病（T1D）患者中的一致性，并分析其使用与临床前动脉粥样硬化识别之间的关系。
我们连续选择年龄≥40 岁、患有肾病和/或 T1D 病程≥10 年且有其他危险因素的无 CVD 的 T1D 患者。通过超声检查确定不同颈动脉段的斑块存在情况。心血管风险根据 ESC/EASD-2019 风险组（中/高/极高）和 Steno-Risk（<10%，低；10-20%，中；≥20%，高）进行评估，作为 T1D 特异性评分。在一项探索性分析中，我们还评估了针对 40-79 岁人群的 2013 年 ACC/AHA 心血管风险评估指南（ACC/AHA-2013）的非 T1D 特异性汇总队列方程。
我们纳入了 501 名患者（53%为男性，平均年龄 48.8 岁，中位 T1D 病程 26.5 年，41.3%有斑块）。T1D 特异性量表之间的一致性较差（κ=0.19）。根据 Steno-Risk 类别，斑块的存在呈阶梯式增加（低、中、高危分别为 18.4%、38.2%和 64.1%；趋势 P<0.001），与 ESC/EASD-2019 无差异（P=0.130）。Steno-Risk 能够识别出有斑块的患者，而 ESC/EASD-2019 则不能（曲线下面积 [AUC] 0.691，P<0.001，vs. AUC 0.538，P=0.149）。最后，在多项式回归模型中（调整血脂参数和心脏保护治疗后），无论 ESC/EASD-2019 类别如何，Steno-Risk 的高危与动脉粥样硬化直接相关（在 ESC/EASD-2019 中为中度/高危，存在斑块的比值比为 2.91 [95%CI 1.27-6.72]，存在两个或更多斑块的比值比为 4.94 [2.35-10.40]）。对于与 ACC/AHA-2013 不相符的更高的 Steno-Risk，也得到了类似的结果（P<0.001）。
在接受一级预防的 T1D 患者中，与 ESC/EASD-2019 相比，使用 Steno-Risk 似乎可以更好地识别出有动脉粥样硬化的患者。尽管如此，颈动脉超声检查可能会改善心血管风险的分类。
