Columbus, OH — May 2017
Body mass index, lipids, blood pressure — all are “traditional” ways of assessing cardiovascular risk in patients with type 1 diabetes, and all are important as far as they go. But it’s vital that more specific “nontraditional” markers be identified to predict the progress of actual cardiovascular disease for these patients.
Those markers could point to patients most in need of special intervention and help to evaluate whether those interventions are effective. Robert Hoffman, MD, a member of the Section of Endocrinology at Nationwide Children’s Hospital, recently published a review of the research on specific markers and highlighted their potential usefulness.
None are quite ready for regular clinical use, however, as he detailed in Current Diabetes Reviews.
“We are still learning what they mean, what they look like when they are normal and abnormal,” says Dr. Hoffman, who is also a professor of Pediatrics at The Ohio State University College of Medicine. “There is very good evidence that heart disease has its beginnings in pediatrics. We need to be able to figure out who is at risk as soon as possible, and these nontraditional factors may be able to help.”
Biochemical markers perhaps are most sought after, because they could involve only a blood or urine measurement. C-reactive protein, an indicator of inflammation, is the most studied biochemical marker in pediatric type 1 diabetes. Dr. Hoffman says there is reason to believe its measurement will be standardized soon for pediatrics.
Other possible biochemical markers include the cytokines tissue necrosis factor-α, interleukin-6 and interleukin-18, as well as indicators of oxidative stress and anti-oxidant defense, such as vitamins C and E, glutathione and superoxide dismutase.
Static and dynamic measures of vascular function may also ultimately help identify cardiovascular risk in children with type 1 diabetes. Carotid artery intima medial thickness is the most commonly used static measure, though some evidence indicates that thickness measurements in the aorta are more useful. Both kinds of measurement are age-, sex- and technique-dependent.
Augmentation index and pulse wave velocity assess vascular stiffness and have been studied in adolescents. Again, standardization has been difficult.
For now, the best advice for physicians and patients is the usual advice, says Dr. Hoffman.
“Focus on glucose, on lipids, on blood pressure,” he says. “We all say that the goal of diabetes care is preventing long-term complications, and we do that by forcing good blood sugar control. That’s not easy and puts a lot of demands on the patient. If these mechanistic studies can lead to identification of markers, and in turn help us find a way of preventing a specific complication, that will help.”
Hoffman RP. Nontraditional cardiovascular risk factors in pediatric type 1 diabetes. Current Diabetes Reviews. 2016 Dec 1. [Epub ahead of print]