Patients with stable chest pain symptoms but a low likelihood of CAD can safely be diagnosed as not having obstructive CAD in the absence of detectable coronary calcification by unenhanced CT. Patients with CAC >400 Au have a high prevalence of obstructive CAD and further investigation with ICA or functional imaging may be warranted rather than CTCA. These findings support NICE guidance for the investigation of stable chest pain. ClinicalTrials gov identifier: NCT01464203.
Background
The value of screening sub‐clinical atherosclerosis in asymptomatic patients with type 2 diabetes mellitus (T2DM) remains controversial.
Hypothesis
An integrated model incorporating carotid intima‐media thickness (CIMT) and carotid plaque with traditional risk factors can be used to predict prevalence and severity of coronary artery calcification in asymptomatic T2DM patients.
Methods
A cohort of 262 asymptomatic T2DM patients were prospectively studied with carotid ultrasound to evaluate CIMT and carotid plaque and also a computed tomography coronary artery calcium (CT‐CAC) scan.
Results
Carotid plaque was detected in 124 (47%) patients and mean CIMT was 0.75±0.14 mm. Two hundred (76%) patients had a CAC score >0, of whom 57 (22%) had severe coronary atherosclerosis (>400 Au). In this group, carotid plaque was present in 40 (70%) patients (p<0.001).
Univariable analysis revealed significant associations between non‐zero CAC score and age (p<0.001), hypertension (p=0.01), gender (p=0.003) and duration of diabetes (p=0.004). Carotid plaque and mean CIMT were also significantly associated with non‐zero CAC score (odds ratios [95% CI], 3.12 [1.66 ‐5.85] and 2.98 [0.24 ‐7.17], respectively). After adjusting for traditional risk factors, carotid plaque continued to be predictive of non‐zero CAC score (2.59 [1.17 ‐5.74]) and CIMT was borderline significant (p=0.05). When analysed with binary logistical regression, the prevalence of carotid plaque significantly predicted severe CAC burden (CAC >400 Au; 3.26 [2.05 ‐5.19]). Upper CIMT quartiles showed a similar association (2.55 [1.33 ‐4.87]).
Conclusion
Carotid plaque is more predictive of underlying silent coronary atherosclerosis prevalence, severity and extent in asymptomatic T2DM patients.
Endothelial dysfunction is common in patients with type 2 diabetes mellitus (T2DM) and is associated with atherosclerotic disease. This study aimed to determine prognostic factors for endothelial dysfunction and identify relationships between reactive hyperemia index (RHI) score, clinically relevant coronary artery disease (>50% stenosis), and major adverse cardiovascular events (MACEs) in patients with T2DM. Endothelial function was assessed using peripheral arterial tonometry and correlated with patient characteristics and cardiovascular outcomes during a median follow-up of 22.8 months. Among 235 patients with a median duration of T2DM of 13 years, mean (standard deviation) RHI score was 2.00 (0.76). Serum low- and high-density lipoprotein cholesterol levels positively ( P = .004) and negatively ( P = .02) predicted RHI score, respectively. Median coronary artery calcium (CAC) score was 109 Agatston units, but no correlation between CAC and RHI scores was observed. The RHI score did not predict the number or severity of coronary plaques identified using computed tomography coronary angiography. Additionally, there was no association between RHI score and the risk of an MACE during follow-up. Overall, endothelial function was not predictive of CAC score, extent, and severity of coronary plaque or MACEs and did not demonstrate utility in cardiovascular risk stratifying patients with T2DM.
Background
Carotid intima media thickness (CIMT) has been used as a risk stratification tool for coronary artery disease (CAD). However, there is insufficient prospective data regarding carotid plaque (CP) and severity of CAC in asymptomatic diabetic subjects.
Aim
Our aim was to determine if CIMT and presence of CP were predictors of prevalence and severity of CAC.
Methods
One hundred and eight (n = 108) diabetic patientsrecruited for the PROCEED study (Progression of Coronary Atherosclerosis in Asymptomatic Diabetic Subjects – Evaluation of the role of CT Coronary Angiography and bio-markers of Endothelial Dysfunction and Vascular Inflammation) a prospective study in asymptomatic Type II diabetic subjects, evaluating the progression of atherosclerosis, underwent both carotid ultrasound and CAC scan. Measures of carotid atherosclerosis include CIMT and presence of carotid plaque. Coronary calcium scan was done by dual source multi slice scanner ((Siemens Medical Systems, Forchheim, Germany) and carotid ultrasound was performed using 9–12 MHz linear transducer (GE Vivid E9).
Results
The mean age of the study population was 61.3 + 8.7 years and Body Mass Index (BMI) 31.1 + 6.8. There were 65 (60.2%) males, 9 (8.3%)with h/o current smoking, 87(80%) with hypertension, 71 (65.7%) with hyperlipidaemia, 50 (46%) with micro vascular disease and 15 (13.9%) with a h/o premature ischaemic heart disease (IHD) .
Mean CIMT was 0.82 ± 0.17 mm and CP was noted in 43(40%) patients. Mean CIMT did not differ significantly in patients with micro-vascular disease (MVD) as compared to those without (0.85 ± 0.18 mm vs 0.80 ± 0.17 mm). 32 (30%) patients had a CAC score of zero.76 (70%) had CAC >0, of which, 53(49%) had CAC score 1–400 and 23(21%) had a CAC score > 400. Association between CAC and CP was stronger on univariate (p = 0.002) and borderline on multivariate (p = 0.05) regression analysis. A significant association between prevalence of carotid plaque and severe CAC (>400Au) was noted in a Chi square analysis (p 0.019), Odds Ratio of 3.81 (95% CI of 1.44–10.06) whereas correlation between CAC and IMT was poor(r = 00.03) on bivariate analysis.
Conclusion
Presence of CP was independently associated with severity of CAC whereas CIMT was not, even in this high risk diabetic population. Carotid plaque evaluation may have important clinical implication by identifyingsub group of high risk population in asymptomatic diabetes.
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