Microvascular disease burden tied to CVD outcomes in diabetic patients

By Eleanor McDermid

The risk of cardiovascular disease (CVD) events in patients with Type 2 diabetes rises in line with their cumulative burden of microvascular disease, research shows.

The research, published in The Lancet Diabetes & Endocrinology, included data on 49,027 patients with Type 2 diabetes identified in the UK Clinical Practice Research Datalink. It shows that the patients' likelihood of having a major CVD event increased according to the number of microvascular disease manifestations they had, these being retinopathy, microalbuminuria and peripheral neuropathy.

Naveed Sattar (University of Glasgow, UK) and David Preiss (University of Oxford, UK) write in an accompanying commentary that the study, "while reinforcing established wisdom, does so in a manner which is potentially clinically impactful."

They say the results highlight the need for statin therapy and intensive blood pressure control in diabetes patients, "particularly patients younger than 40 years in whom guidelines are often less prescriptive." And they suggest that the presence of microvascular disease in more than one tissue should trigger intensification of lipid-lowering therapy.

Microvascular disease was common, with 18,631 patients having at least one type, 13,886 patients two types and 4125 having all three. Glycated haemoglobin levels rose with increasing number of microvascular disease manifestations, and the same was true of blood pressure, while renal function declined.

The exception to this trend of worsening risk factors was levels of total and low-density lipoprotein cholesterol levels. These improved, which Jack Brownrigg (St George's University of London, UK) and study co-authors attribute to more intensive statin therapy among patients with more overt microvascular complications.

The rate of a first major CVD event (nonfatal myocardial infarction or stroke, or vascular death) rose from 5.00 per 1000 person-years among patients with no microvascular complications to 9.82, 15.69 and 22.10 per 1000 person-years among those with one, two and three complications, respectively.

And this relationship persisted after accounting for confounders, including glycated haemoglobin levels, duration of diabetes and social deprivation. Specifically, patients with one, two and three complications were a significant 32%, 62% and 99%, respectively, more likely to have a major CVD event than those with none.

Having microvascular disease also increased patients' risk of being hospitalised with heart failure and of CVD death, with three manifestations increasing the risk a respective 2.90- and 2.53-fold.

Notably, the risk associated with microvascular disease varied according to whether patients' CVD risk factors were well controlled. Among those with three microvascular disease manifestations, the rate of CVD events was 29.8 per 1000 person-years for those with poor control, but 17.1 per 1000 person-years for those with well controlled glycated haemoglobin, blood pressure and lipid levels.

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Lancet Diabetes Endocrinol 2016; Advance online publication


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