October 24, 2025

Leads:

Carol Levy – Mt. Sinai (Adult)

Emily Coppedge – Cornell (Peds

Meeting Agenda:

Cardiovascular Guidelines in Type 2 Diabetes

There’s a lot of cardiovascular guidelines in type 2 diabetes, but vague data and underrepresentation in clinical trials on type 1 diabetes.
A QI project aims to identify patients who may need statins based on age, diabetes duration, and LDL levels.

Data on Type 1 Diabetes and Cardiovascular Disease

Incidence of type 1 diabetes is increasing.
Adolescents with type 1 diabetes may show subclinical atherosclerosis.
56% of type 1 diabetes from T1D registry are overweight or obese.
Diagnosis of type 1 diabetes before age 10 increases risk for heart disease.
Cardiovascular events in type 1 diabetes have a higher rate than in patients with type 2 diabetes.
Swedish study showed a fourfold higher incidence of cardiovascular disease in individuals diagnosed with diabetes before age 10 compared to those diagnosed at ages 26-30.
There is a lack of data to support extrapolating Framingham criteria from type 2 diabetes to type 1 diabetes.

Steno T1D Risk Score Engine

A study in Denmark developed a cardiovascular disease prevention model using over 4,000 adults with type 1 diabetes.
Cardiovascular disease was defined as a composite of fatal and non-fatal events, including ischemic heart disease, stroke, heart failure, and peripheral arterial disease.
The study used a two-stage approach with non-parametric and regression analysis.
The study found that one-third of patients with type 1 diabetes were diagnosed over the age of 30.
The average age of the cohort was 42, with an average BMI of 24.
The average age of diagnosis was 20, and the average diabetes duration was 16-17 years.
The Steno risk model includes albuminuria and eGFR, which are not included in the Framingham model.
The model also incorporates diabetes duration, A1C, and regular exercise.

Hyperglycemia and Cardiovascular Disease Risk

The Pittsburgh Epidemiology of Diabetes Complication (EDC) Trial evaluated the association of longitudinal A1C with total cardiovascular disease incidence.
Patients with low A1C showed more association of cardiovascular disease with usual risk factors: non-HDL, EGFR, smoking, systolic blood pressure, and Mace.
For higher A1C, kidney disease was more of a determinant for cardiovascular events compared to traditional risk factors in the low A1C group.
Traditional factors may be overshadowed by A1C.
Chronically elevated A1C likely produces direct vascular damage.
Albumin excretion ratio and cardiovascular disease also result in hyperglycemia and vascular damage, affecting both kidneys and cardiovascular system.

Treatment Considerations

In low A1C, traditional obese factors are more important.
In low A1C treatment effect, consider targeting traditional factors for cardiovascular disease (hyperlipidemia, blood pressure control) for someone with A1C of 7.2-7.3%.
Family history of myocardial infarction was a significant risk factor only for the low A1C group.

Virtual CGM Study Findings

Virtual CGM profiles were used to compute CGM metrics and predict micro and macrovascular complications from original DCCT trials (excluding EDIC trial follow up).
Data tightly correlated with A1C data. Time in range prediction was closely correlated with A1C.
Time below range possibly associated with low risk (not statistically significant).
Virtual CGM metrics are associated with cardiovascular outcomes in people with type 1 diabetes.
Supports including CGM metrics in clinical trials as primary endpoint in cardiovascular trials for type 1 diabetes.

Study on Adverse Outcomes After Hospital Discharge

The study looked at data within six months after discharge from the hospital.
Data was obtained from outpatient records.
Chronic kidney disease was repeatedly shown as a significant risk factor.
Peripheral neuropathy and the number of hypoglycemic episodes were also statistically significant.
In multivariate analysis, peripheral neuropathy remained highly significant.

Impact of Type 1 vs. Type 2 Diabetes on Myocardial Infarction Outcomes

A study evaluated diabetes as a risk factor for adverse outcomes after acute myocardial infarction using a national inpatient sample database.
Type 1 diabetes patients had a higher percentage of MACE compared to those with type 2 diabetes and no diabetes.
Cardiovascular mortality, overall mortality, major bleeding, and stroke were all higher in type 1 diabetes.
Hyperglycemia increases oxidative stress, vascular inflammation, monocyte adhesion, arterial wall thickening, and endothelial dysfunction.

Metformin in Type 1 Diabetes

Several studies show some benefit of metformin.
Metformin reduces plasma level of glycated but not oxidase low density lipoprotein in young patients with type 1 diabetes and obesity.
After six months of treatment, those receiving metformin showed substantial reduction A1C some reduction BMI LDL and triglycerides level.
Systematic reviews have shown that metformin reduces insulin needs.
Lower insulin dose may lead to less weight gain and hypoglycemia.

Statin Use in Type 1 Diabetes

In type 1 diabetes, statins may be less effective because the pathophysiologic mechanism is increased absorption of cholesterol, not increased production.
Zetia could be more effective or added to statins.
Challenges in cardiovascular research in type 1 diabetes.
Small representation of type 1 diabetes in cardiovascular safety trials.
Lack of type 1 specific cardiovascular outcomes trials using cholesterol lowering medications.
Health heart protection study showed individuals with type 1 diabetes had the same benefit as individuals with type 2 diabetes with Simvastatin treatment.

Other topics covered: