Diabetes in Middle Age Linked to Earlier CVD Risk: Danish Study

A diagnosis of type 2 diabetes lowers the age threshold for 10-year risk of CVD, a large Danish study suggests, meaning that some middle-aged individuals could be at risk a decade earlier or more than people of similar age without diabetes.

Across all ages, the 10-year risks of nonfatal MI, nonfatal stroke, and fatal CVD were higher in those with a diabetes diagnosis, but the most pronounced disparities were seen in people in their 40s and 50s where a new diabetes diagnosis increased risk by more than twofold compared with individuals of the same age without diabetes.

In men, the 10-year CVD risk of 5% was reached at age 43 for those with diabetes versus age 55 in those without diabetes. Similarly in women, a diabetes diagnosis lowered the age, from age 61 to age 51, at which they reached the 10-year CVD risk of 5%.

Senior study author Michael Maeng, MD, PhD (Aarhus University Hospital, Denmark), noted that current treatment guidelines, including those from the European Society of Cardiology (ESC) for the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD), do not provide strong recommendations for the management of these newly diagnosed younger patients.

“These young type 2 diabetes patients are the ones with the highest relative risk and longest life span ahead of them,” Maeng said in an email. “Therefore, we find that there is an unmet need for optimized treatment.”

Taken with other recent data, the Danish paper adds to a growing picture of significant life-years being lost to CVD in newly diagnosed middle-age diabetic patients compared with those without diabetes.

“No question, this is a call to action for all of us to think about this and take ownership of it much earlier,” Michael J. Blaha, MD, MPH (Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD), told TCTMD. “Obviously, the time is now for us as cardiologists to take this on.”

Developing diabetes in middle-age as opposed to later in life is commonly associated with marked metabolic changes like obesity, inflammation, hypertension, and sleep apnea, but it’s prognostic significance for CVD often goes underappreciated in younger age groups where diabetes is flourishing, Blaha added.

“I think this is a very important paper for articulating the problem and for communicating to patients or even guideline writers and public health folks,” he noted. “It can put the risk in perspective and build from there.”

The study was published October 9, 2023, in the Journal of the American College of Cardiology.

Relative Risk of CVD Far Greater in Young vs Elderly

For the study, Maeng and colleagues led by Christine Gyldenkerne, MD (Aarhus University Hospital), looked at 10-year risk of CVD in 142,587 patients without known ASCVD who were diagnosed with diabetes between 2006 and 2013, and a cohort of 388,410 age- and sex-matched individuals from the general population with no history of diabetes or prior ASCVD.

Compared with patients diagnosed with diabetes later in life, those diagnosed before age 50 had higher rates of obesity and received fewer prophylactic medications, including statins and antihypertensives.

Over a median follow-up of 8.1 years, patients with newly diagnosed diabetes had a 10-year cumulative incidence of CVD of 12% versus 9.3% in the general population, as well as higher rates of the individual components of CVD (MI, stroke, and fatal CVD).

When the analysis was stratified by age, there was a stepwise increase in the 10-year risk of CVD with increasing age. This ranged from 2% in those under 40 years of age to 30% in patients who were 80 years of age or older. However, the relative increased risk of CVD in newly diagnosed diabetic patients versus the general population was much smaller in the elderly at only 0.3% for those aged 80 and older compared with 2.8% among 40-year-olds and 2.7% among 50-year-olds.

Across all age groups, men with newly diagnosed diabetes had greater 10-year risks of CVD than women, particularly in younger age groups.

Early, Team-Based Coordination Needed

“We need to have an aggressive approach to treat these patients when they are diagnosed, no matter if the diagnosis is made by the general physician, a cardiologist, or any other specialty,” Maeng told TCTMD.

In an editorial accompanying the paper, Blaha and Michael Khorsandi, MD (Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease), maintain that it is hard to imagine any other area of CV medicine that is poised to “have a bigger impact on the health of our society in 2050 than the earlier and more evidence-based treatment of cardiometabolic disease.”

Recent large CV outcome trials of diabetes therapies, and the success of GLP-1 receptor agonists and SGLT2 inhibitors in reducing CVD risk, have ushered in an era where cardiologists should now become active caregivers for those with new-onset type 2 diabetes, they add. A drawback to adopting that approach is that cardiologists don’t receive any or enough training in obesity, lifestyle, and diabetes management during their training. 

What’s needed now, Blaha and Khorsandi say, is an overhaul of the US healthcare system to create a “dedicated home” for the care of cardiometabolic patients.

“The primary care doctor is trying to handle this, but does not have the time to really put in all the lifestyle coaching, the risk-factor control discussions that are required,” Blaha said. “So, it really needs to be a team effort and needs to start early and it needs be recognized that these are distinct disorders. Obesity, diabetes, heart disease—these are all the same disease with different manifestations and when you think about it this way, communication and team-based care becomes more obvious and becomes more necessary.”