Ischaemic heart disease

Cardiovascular preventive care neglected for most young Australians with diabetes


Young people with type 1 diabetes are not getting recommended cardiovascular risk assessments and treatments, a South Australian study shows.

Researchers at the Women and Children’s Hospital, Adelaide, say monitoring and treatment of cardiovascular risk factors during childhood and adolescence is an essential part of diabetes care because cardiovascular disease is the primary cause of increased morbidity and reduced longevity in type 1 diabetes.

However their study of 11,562 Australian and New Zealand patients with T1D aged two to 25 years found very few received recommended blood pressure (BP), lipid or urinary albumin-creatinine ratio (ACR) tests, and fewer still received treatment for existing cardiovascular risk factors.

During the eight-year study, two in five patients under 11 and a third of those 11 and over had no BP measurements recorded at follow-up appointments. Fewer than half the patients under 11 and 60% of patients 11 years and older had two or more  BP measurements.

Lipid measurements were not reported in 82% and 50% of patients aged under 11 and over 11, respectively, while 5% and 31% of patients received two or more measurements.  For ACR measurements , 95% of children under 11 and 61% of patients over 11 had none reported, while less than 1% and 24% respectively had two or more measurements.

In respect of cardiovascular risk interventions, only two patients under 11 received treatment for any CVD risk factor — with both receiving statins for abnormal lipid profiles.

Meanwhile, less than 4%, 1% and 7% of eligible patients 11 years and older received BP, lipid or ACR lowering therapies at their last visit respectively.

“We report low rates of assessment and particularly low rates of pharmaceutical treatment for abnormal cardiovascular risk factors,” the authors wrote in Diabetes, Obesity and Metabolism.

“As expected, duration of T1D was longer in those who received treatment for any risk factor, and BMI was higher in those treated for an abnormal lipid profile,” however, gender, HbA1c and patient locale made little difference to assessment or treatment access, they wrote.

“These findings are noteworthy: the centres were in teaching hospital settings, and clearly the endocrinologists were circumspect about prescribing life-long statins, in particular in young people.”

They “highlight the need to [prioritise] discussion around the uptake of screening and pharmaceutical intervention guidelines for the prevention of premature cardiovascular disease in young people with T1D, in addition to interventions to improve metabolic control”.

Currently, the International Society of Paediatric and Adolescent Diabetes (ISPAD) guidelines recommended all young patients get their blood pressure be tested annually and receive angiotensin-converting enzyme inhibitors (ACEis) when their “average systolic [blood pressure] and/or diastolic [blood pressure] that is ≥95th percentile for gender, age, and height on three or more occasions”.

ACEis “have been effective and safe in children in short-term studies, but are not safe during pregnancy,” they noted.

They further recommend lipids be screened in patients 11 and over “soon after diagnosis (when diabetes is stabilised)” and every five years if readings are normal.

Patients may be screened earlier, however, if they have an unknown family history or one featuring hypercholesterolaemia or early cardiovascular disease. This caveat helps support the low testing rates in this study’s under 11 cohort.

High low density lipoprotein (LDL) cholesterol is defined as > 2.6 mmol/L, the guidelines state. Where lifestyle changes and improved metabolic control fail to reduce LDL to below 3.4 mmol/L, statins should be started in children aged 11 and over.

Similarly, annual ACR screening should start in 11+ year olds with two to five years diabetes duration, the guidelines read.

Those with persistent albuminuria should receive ACEis or angiotensin receptor blockers to prevent proteinuria, they recommended.

With younger patients at higher risk of adulthood cardiovascular disease, guideline adherence is critical, the study authors suggested.

“Further investigation will explore solutions to increase the frequency of assessments and to guide appropriate treatment for cardiovascular risk, both from the physicians’ and the patients’ perspectives,” they concluded.

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