Coronary Plaque Burden in T1D
Charlotte E. Vollenbrock, Delnaz Roshandel, Kristine E. Lee, Barbara E. Klein, Dick Mul, Melanie M. van der Klauw, Cornelis J. Tack, Marian Rewers, Janet K. Snell-Bergeon, Tina Costacou, Rachel G. Miller, Maria Luiza Caramori, Mike Mauer, Henk-Jan Aanstoot, Bruce H.R. Wolffenbuttel, Andrew D. Paterson, DCCT/EDIC Research Group
Association of genetic variation with age at diagnosis in type 1 diabetes. BMJ Open Diabetes Res Care. 2026 Jan 16;14(1):e003877. Epub 2026 Feb 13.
Cardiovascular disease remains the leading cause of death in adults with type 1 diabetes (T1D), and current guidelines recommend initiating statin therapy at age 40. But is that early enough? Given that people with T1D carry an elevated lifetime cardiovascular risk, there are legitimate concerns that atherosclerotic plaque may already be accumulating well before that threshold. This study, co-authored by Diabeter NL/Diabeter Center Amsterdam authors Henk-Jan Aanstoot en Dick Mul, set out to answer that question directly — by imaging the coronary arteries of middle-aged people with long-standing, well-regulated T1D and comparing their plaque burden to that of healthy controls.
Using coronary CT angiography (CCTA) combined with AI-driven quantitative plaque analysis (AI-QCT), 58 individuals with T1D (mean age 42 years, median disease duration 24 years, all CGM users) were compared to 45 age- and sex-matched healthy controls. The T1D group was well regulated, with a median time in range of 71% and a mean HbA1c of 55 mmol/mol. Lipid-lowering therapy and prior cardiovascular events were exclusion criteria. Within the T1D group, the researchers also explored whether CGM metrics were associated with plaque burden.
Key findings:
- Similar coronary plaque burden in T1D and healthy controls: The prevalence of significant coronary plaque was 31% in the T1D group versus 22% in controls — a difference that was not statistically significant after adjusting for clinical risk factors. Plaque volumes and the presence of high-risk plaque were also comparable between groups.
- CGM metrics not associated with plaque: Time in range, time above range, time below range, glucose coefficient of variation, and cumulative HbA1c exposure were all not significantly associated with coronary plaque volumes. This likely reflects the relatively well-regulated nature of the T1D cohort rather than an absence of any relationship.
- LDL-C is the key driver: In contrast to glycaemic metrics, every 0.5 mmol/L increase in LDL-C was significantly associated with a 34% relative increase in atheroma volume and a 60% relative increase in calcified plaque volume — underscoring the primacy of lipid management in cardiovascular risk reduction.
- Diabetic retinopathy signals higher plaque burden: The presence of diabetic retinopathy was significantly associated with higher atheroma volume, non-calcified plaque volume, and calcified plaque volume, suggesting it may serve as a marker of systemic vascular risk.
- Encouraging signal for modern diabetes management: The findings contrast with older studies showing markedly higher plaque burden in T1D, and the authors suggest that advances in insulin pump therapy and CGM — combined with tight control of lipids and blood pressure — may be contributing to a genuine reduction in cardiovascular risk.
These results offer cautious optimism that well-managed T1D, with on-target lipid levels and blood pressure, may no longer carry the same atherosclerotic burden once assumed. At the same time, the authors stress that LDL-C remains a potent, modifiable risk factor even in this group, and that longer-term follow-up is needed to determine whether this favourable plaque profile is maintained over time.
Concluding, the authors state
"These results therefore call for cautious optimism for the future and large-scale studies should reveal whether outcomes in type 1 diabetes will indeed improve further by focusing on improving glycemic control and risk factor modification." -
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