The Steno Type 1 Risk Engine identifies preclinical atherosclerosis better than the ESC/EASD-2019 Guidelines in adult subjects with type 1 diabetes at high-risk

Objective: To evaluate the concordance between the ESC/EASD-2019 and the Steno Type 1 Risk Engine (Steno-Risk) cardiovascular risk scales in persons with type 1 diabetes (T1D) without cardiovascular disease (CVD), and to analyze their relationships with preclinical atherosclerosis.

Research design and methods: We consecutively selected patients with T1D, without CVD, with: ≥40 years, nephropathy, or ≥10 years of evolution with another risk factor. The presence of plaque at different carotid segments was determined by ultrasonography. Cardiovascular risk was estimated according to ESC/EASD-2019 risk groups (moderate/high/very-high) and the Steno-Risk (<10%, low; 10-20%, moderate; ≥20%, high), as T1D-specific scores. As an exploratory analysis, the non-T1D-specific ACC/AHA-2013 pooled cohort equation was also evaluated in individuals between 40-79 years.

Results: We included 501 patients (53% males, age 48.8 years, T1D duration 26.5 years, 41.3% harboring plaques). Concordance between T1D-specific scales was poor (kappa= 0.19). A stepped increase in the presence of plaques according to the Steno-Risk category was seen (18.4%, 38.2% and 64.1%, for low/moderate/high-risk; p for trend<0.001), with no differences according to ESC/EASD-2019 (p=0.130). Steno-Risk identified individuals with plaques, unlike ESC/EASD-2019 (AUC=0.691; p<0.001 vs. AUC=0.538; p=0.149; respectively). Finally, in polynomial regression models (adjusted for lipid parameters and cardioprotective treatment), irrespective of the ESC/EASD-2019 category, high-risk by Steno-Risk was directly associated with atherosclerosis (in moderate/high-risk ESC/EASD-2019: OR 2.91 [1.27-6.72] and 5.290 [2.746-10.189], for the presence of plaque and ≥2 plaques, respectively). Similar results were obtained with discordant higher Steno-Risk vs. ACC/AHA-2013 (p<0.001).

Conclusions: In T1D patient undergoing primary prevention, Steno-Risk seems to better recognize individuals with atherosclerosis in comparison to ESC/EASD-2019. Notwithstanding, carotid ultrasound could improve the categorization of cardiovascular risk.