Diabetic patients without overt heart disease demonstrate evidence of systolic dysfunction and increased myocardial reflectivity. Although these changes are similar to those caused by LVH, they are independent and incremental to the effects of LVH.

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Dobutamine echocardiography is an independent predictor of death, incremental to other data. While a normal dobutamine echocardiogram predicts low risk of cardiac death (on the order of 1% per year), this risk increases with the extent of abnormal wall motion at rest and stress.

OBJECTIVE -This study sought to determine whether stress echocardiography using exercise (when feasible) or dobutamine echo could be used to predict mortality in patients with diabetes. RESEARCH DESIGN AND METHODS -Stress echo was performed in 937 patientswith diabetes (aged 59 Ϯ 13 years, 529 men) for symptom evaluation (42%) and follow-up of known coronary artery disease (CAD) (58%). Stress echocardiography using exercise was performed in 333 patients able to exercise maximally, and dobutamine echo using a standard dobutamine stress was used in 604 patients. Patients were followed for Յ9 years (mean 3.9 Ϯ 2.3) for all-cause mortality.RESULTS -Normal studies were obtained in 567 (60%) patients; 29% had resting left ventricular (LV) dysfunction, and 25% had ischemia. Abnormalities were confined to one territory in 183 (20%) patients and to multiple territories in 187 (20%) patients. Death (in 275 [29%] patients) was predicted by referral for pharmacologic stress (hazard ratio [HR] 3.94, P Ͻ 0.0001), ischemia (1.77, P Ͻ 0.0001), age (1.02, P ϭ 0.002), and heart failure (1.54, P ϭ 0.01). The risk of death in patients with a normal scan was 4% per year, and this was associated with age and selection for pharmacologic stress testing. In stepwise models replicating the sequence of clinical evaluation, the predictive power of independent clinical predictors (age, selection for pharmacologic stress, previous infarction, and heart failure; model 2 ϭ 104.8) was significantly enhanced by addition of stress echo data (model 2 ϭ 122.9).CONCLUSIONS -The results of stress echo are independent predictors of death in diabetic patients with known or suspected CAD. Ischemia adds risk that is incremental to clinical risks and LV dysfunction. Diabetes Care 25:1042-1048, 2002A pproximately 50% of mortality in diabetic patients is related to coronary disease (1), and diabetes has a significant impact on outcome in patients with established coronary disease (2). This increased risk in the diabetic population is equivalent to the risk of nondiabetic patients after infarction (3), a finding that has engendered calls for more aggressive risk factor intervention in this group. A further strategy would be to screen patients for existing evidence of coronary disease, with the intent of myocardial revascularization in those at greatest risk. In nondiabetic patients, a number of factors may be used to stratify the level of risk of coronary disease, including clinical history, resting ventricular function, exercise capacity, the presence and extent of ischemia at single-photon emissioncomputed tomography (SPECT), or stress echo. The detection of a spectrum of risk within the diabetic group is more difficult; sex and lipids levels are less predictive in diabetic than nondiabetic patients (4), and silent ischemia is more common (5). However, resting ST segment changes may be false positive responses for epicardial coronary disease (5), and false positive ST segment changes and poor exercise capacity may reduce the utility of standard exercise el...

Brachial artery reactivity is lower in patients with events, but is not an independent predictor of cardiovascular outcomes in this cohort of patients.