Thirty-seven million adults in the United States and 537 million adults worldwide have diabetes.[1] By 2045, diabetes prevalence is projected to grow by 16% to affect 783 million people worldwide. While diabetes is associated with numerous medical complications, cardiovascular disease remains the leading cause of morbidity and mortality among persons with diabetes, often presenting earlier and in a more severe form than among individuals without diabetes. Diabetes confers a higher risk of multiple forms of cardiovascular disease, including ischemic heart disease, heart failure (HF), stroke, and peripheral artery disease, each of which has distinct implications for prevention and management strategies.[2] Therefore, understanding and addressing cardiovascular disease risk is a principal consideration for improving clinical outcomes in patients with diabetes.
In this issue of Circulation, Sattar et al[3]analyzed [almost equal to]680 000 patients with diabetes in the Swedish National Diabetes Register and [almost equal to]2.6 million age-, sex-, and county-matched controls to examine patterns in the incidence rates of multiple cardiovascular outcomes (ie, coronary artery disease, myocardial infarction, cerebrovascular disease, and HF) among persons with diabetes over the past 2 decades. Between 2001 and 2019, there was a continuous decline in rates of atherosclerotic cardiovascular disease (ASCVD) events among individuals with diabetes. The incidence rate (per 10 000 person-years) of acute myocardial infarction decreased from 74 to 41, coronary artery disease from 205 to 80, and cerebrovascular disease from 84 to 46. These ASCVD trends contrasted with the trends for HF among individuals with diabetes. After a period of declining HF rates from 1999 to 2013, the incidence of HF in diabetes plateaued over the past 5 years of follow-up. Furthermore, when modeling time period as the exposure, risks for acute myocardial infarction, coronary artery disease, and cerebrovascular disease have decreased over time among persons with diabetes and matched controls. In contrast, although the risk for HF has decreased slightly over time in controls, HF risk has increased temporally in those with diabetes. This work highlights a substantive shift in the predominant phenotype of cardiovascular disease in diabetes, with HF to become the most frequent cardiovascular complication in diabetes if current trends persist.
