Type 1 diabetes raises the risk for atrial fibrillation, particularly in women, new research suggests.
Findings from the large registry-based, prospective, case-controlled study were published online August 21 in Lancet Diabetes & Endocrinology by Sofia Dahlqvist, department of medicine, NU Hospital Group, Uddevalla, Sweden, and colleagues.
The Swedish study, believed to be the first to investigate atrial fibrillation in type 1 diabetes, involved more than 36,000 patients with type 1 diabetes, each matched with five nondiabetic controls. Over about 10 years’ follow-up, of those with type 1 diabetes, the risk for atrial fibrillation was 50% greater for women and only slightly elevated among men. The excess risk was also linked to worse glycemic control and renal complications.
“Our study findings highlight the importance of keeping HbA1c values within recommended ranges and controlling renal complications. Clinicians should be aware of risk factors such as older age, severity of renal complications, poor glycemic control, hypertension, and coexisting cardiovascular disease when screening for atrial fibrillation,” the authors write.
They also note that “although the excess risk of atrial fibrillation was greater in women, the absolute risk of atrial fibrillation was somewhat greater in men, indicating sex alone is not the only variable to screen in the clinical setting.”
In an accompanying editorial, Kazuo Miyazawa, MD, of the Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK, and Gregory Lip, MD, of the Thrombosis Research Unit, Aalborg University, Denmark, note that the finding could reflect the fact that people with type 1 diabetes are typically diagnosed at a younger age than those with type 2 diabetes, and therefore could be predisposed to atrial fibrillation due to longer duration of diabetes exposure.
“Given the relation of diabetes duration and diabetic complications with atrial fibrillation and its complications, atrial fibrillation could be viewed as yet another manifestation of end-organ damage in diabetes,” Drs Miyazawa and Yip write. They advise that until more specific data are available in the type 1 diabetes population, cardiovascular risk management should be similar to that of type 2 patients.
They add that the management of atrial fibrillation “can be simplified by streamlining the patient decision-making pathway for stroke prevention,” such as with the Birmingham three-step pathway (Thromb Haemost. 2017;117:1230-1239).
“Beyond the initial major priority of stroke prevention, the holistic approach to atrial fibrillation management should simply be patient-centred and symptom-directed, and take into account risk factor management.”
Risk Affected by Gender, Age, Kidney Function, and HbA1c
The analysis included 36,258 patients with type 1 diabetes identified in the Swedish National Diabetes Registry between 2001 and 2013, each matched with five nondiabetic controls (n = 179,980) from the Swedish National Patient Registry.
Patients with type 1 diabetes were a mean age of 35.6 years and controls, 35.4 years. Just under half (45%) were women in both groups. Mean diabetes duration was 20 years and mean baseline HbA1c was 8.2%.
During a median follow-up of 9.7 years for the type 1 diabetes group and 10.2 years for the control group, 2% of both groups were diagnosed with atrial fibrillation. This translated to incidence rates of 2.35 vs 1.76 per 1000 person-years for those with type 1 diabetes and controls, respectively.
Because an interaction was found between atrial fibrillation risk and sex, further analyses were done separately for men and women. After adjusting for age, baseline comorbidities, diabetes duration, education, and birthplace, hazard ratios (HR) for atrial fibrillation in those with type 1 diabetes vs controls were 1.13 for men (P = .029) and 1.50 for women (P < .0001).
The risk for atrial fibrillation among men was only significantly elevated compared with controls in those aged 35–49 years (HR, 1.42; P = .0075), whereas the risk among women was elevated in those aged 50–64 years (HR, 1.60; P < .0001) and ≥ 65 years (HR, 1.12; P = .0019).
Increasing HbA1c was also associated with elevated atrial fibrillation risk, with a pronounced rise occurring at HbA1c ≥ 9.7% in men (HR, 2.20) and women (HR, 2.62) (both P < .0001).
The risk for atrial fibrillation was not elevated vs controls among men with type 1 diabetes who had normoalbuminuria or microalbuminuria, but was increased for women with type 1 diabetes in both categories (HR, 1.32; P = .0023, and HR, 1.58; P = .0028, respectively).
In women with normoalbuminuria, an excess risk of atrial fibrillation was seen with an HbA1c of 8.8%–9.6% (HR, 1.98; P = .0008), whereas for men, a significant association was only seen for HbA1c ≥ 9.7% (HR, 1.89; P = .046).
Further research is needed to confirm risk factors and propose specific screening groups for atrial fibrillation, the authors conclude.
Indeed, Drs Miyazawa and Yip add, “Type 1 diabetes is associated with an increased risk of incident atrial fibrillation, and diabetes adds to the risk of adverse outcomes associated with atrial fibrillation and other complications. Further analyses focused on the cardiovascular risks associated with type 1 diabetes and the effects of intensive cardiovascular risk reduction strategies merit serious consideration.”
The study was financed by grants from the Novo Nordisk Foundation, Swedish State, Swedish Research Council, Swedish Heart and Lung Foundation, Swedish Diabetes Foundation, and Diabetes Wellness. Dr Lip is a consultant for Bayer/Janssen, Bristol-Myers Squibb/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Microlife, and Daiichi Sankyo, and a speaker for Bayer, Bristol-Myers Squibb/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche, and Daiichi-Sankyo. Dr Miyazawa reported no relevant financial relationships.
Lancet Diabetes Endocrinol. Published online August 21, 2017. Abstract, Editorial
For more diabetes and endocrinology news, follow us on Twitter and on Facebook.
Tidak ada komentar:
Posting Komentar