Excess mortality and cardiovascular disease in type 1 diabetes in relation to age at onset: a nationwide study of 27,195 young adults with diabetes

By A. Rawshani, N. Sattar, S. Franzén, A. Rawshani, A. Hattersley, A. Svensson, B. Eliasson, S. Gudbjörnsdottir. The Lancet, 2018

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Background We compared individuals with type 1 diabetes (T1D) to matched controls in order to examine how age at diagnosis of T1D relates to excess mortality and cardiovascular (CV) risk. Methods We studied 27,195 persons with T1D in the Swedish National Diabetes Registry, and 135,178 matched controls from the general population. Using Cox regression, and with adjustment for diabetes duration, we estimated excess risk of all-cause mortality, CV mortality, non-CV mortality, acute myocardial infarction (AMI), stroke, CVD (AMI and stroke), coronary heart disease (CHD), heart failure (HF) and atrial fibrillation (AF). Individuals with T1D were categorized into five groups, according to age at diagnosis: 0–9, 10–14, 15–19, 20–24 and 25–30 years. Findings A total of 27,195 persons with T1D and 135,178 controls were included; 924 persons with T1D and 1,405 controls died during follow-up, of which median was 10 years. Patients who developed T1D at 0–10 years of age displayed hazard ratios (95% CI) of 4.11 (3.24–5.22) for death, 7.38 (3.65–14.94) for CV death, 11.44 (7.95–16.44) for CVD, 30.50 (19.98–46.57) for CHD, 30.95 (17.59–54.45) for AMI, 6.45 (4.04–10.31) for stroke, 12.90 (7.30–22.51) for HF and 1.17 (0.62–2.20) for AF. Corresponding figures for those who developed T1D in the age-range 26–30 were 2.83 (2.38–3.37) for death, 3.64 (2.34–5.66) for CV death, 3.85 (3.05–4.87) for CVD, 6.08 (4.71–7.84) for CHD, 5.77 (4.08–8.16) for AMI, 3.22 (2.35–4.42) for stroke and 5.07 (3.55–7.22) for HF; hence excess risk differed up to 5-fold across the diagnosis age. The highest overall incidence rate, noted for all-cause mortality, was 1.9 (95% CI 1.71 to 2.11) per 100.000 person-years for patients with T1D. Developing T1D before 10 years of age resulted in a loss of 17.7 and 14.2 life years for women and men, respectively, whereas years lost were 10.1 and 9.4 in those diagnosed between 26-30 years of age. Interpretation Age at onset of type 1 diabetes is an important determinant of survival, as well as all cardiovascular outcomes, with highest excess risk in females. Greater focus on cardioprotection maybe warranted in those with early onset T1D. Funding Swedish Heart and Lung Foundation

Subfields: Endocrinology, Diabetes and Metabolism, Genetics, Surgery

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