Detection of Coronary Artery Disease in Asymptomatic Patients With Type 2 Diabetes Mellitus

Scognamiglio, R; Negut, Christian; Ramondo, Angelo; Tiengo, Antonio; Avogaro, Angelo

doi:10.1016/j.jacc.2005.10.008

Cited by 209 publications

(154 citation statements)

References 33 publications

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“…26) It already has been shown that the number of risk factors is not associated with the prevalence of coronary artery disease in diabetic patients, because the severity of a risk factor is not similar in each patient. 28,29) Our study again has shown no association between the number of additional risk factors and the prevalence of significant stenosis or high-risk plaque in asymptomatic diabetic patients (Figure 3). …”

Section: Validity Of Coronary Ct Angiography For Screening Testmentioning

confidence: 63%

Role of Coronary CT Angiography in Asymptomatic Patients With Type 2 Diabetes Mellitus

et al. 2012

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SummaryDiabetic patients with coronary artery disease are often asymptomatic, making appropriate care of such patients difficult. The purpose of this study was to investigate the prevalence of coronary lesions in asymptomatic diabetic patients. Coronary computed tomography (CT) angiography was performed in 120 consecutive diabetic patients (90 of whom were men, mean age 65, mean HbA1c 7.2%). Images from patients whose coronary artery calcium scores (CAC scores) were less than 400 were subjected to stenosis and plaque analysis. Significant stenosis was defined as coronary artery stenosis > 70%. High-risk plaque was defined as plaque having both a CT density < 30 Hounsfield Units (HU) and showing positive remodeling. Significant stenoses were identified in 30.5% of the patients. High-risk plaques were identified in 17.1% of the patients. Less than half of the high-risk plaques were obstructive plaques. There was a statistically significant association between significant stenosis and high-risk plaque by chi-square test (P = 0.022). We found significant stenosis even in patients whose CAC score = 0 at a rate of 5.0%. Using univariate logistic-regression analysis, we found that coronary risk factors associated with significant stenosis and high-risk plaque were dyslipidemia (P = 0.033) and current smoking (P = 0.030), respectively. We report for the first time, the prevalence of high-risk plaques in the arteries of patients with asymptomatic diabetes, as assessed by coronary CT angiography. (Int Heart J 2012; 53: 23-28) Key words: Diabetes mellitus, Coronary CT angiography, Asymptomatic diabetes, Vulnerable plaque A cute coronary syndrome is a major health concern in individuals with type 2 diabetes. The quantitative risk of myocardial infarction or cardiac death in diabetic patients is similar to that of patients with a history of myocardial infarction.1) Diabetic patients are also prone to sudden cardiac death.2) However, many diabetic patients are asymptomatic, or have atypical symptoms of coronary heart disease. The reason is thought to be related to autonomic denervation of the heart.3) Therefore, protection of these patients from cardiac events is difficult, and makes the identification of preclinical atherosclerosis even more pressing in diabetic patients.Acute coronary syndrome is mostly triggered by rupture of vulnerable plaque. Recent technological advances such as contrast-enhanced coronary CT angiography now allow the visualization of coronary artery plaques easily and less-invasively. Several studies have used these new techniques to characterize plaque features that are causally related to acute coronary syndrome.4-6) Therefore, it is quite possible that one can now identify vulnerable plaque on CT images.In this cross-sectional study, we analyzed coronary CT angiography findings of asymptomatic diabetic patients. We paid special attention to the analysis of plaque in terms of vulnerability. We believe our report is unique in assessing plaque vulnerability in asymptomatic diabetes. Methods Study des...

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Section: Validity Of Coronary Ct Angiography For Screening Testmentioning

confidence: 63%

Role of Coronary CT Angiography in Asymptomatic Patients With Type 2 Diabetes Mellitus

et al. 2012

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“…Although some studies have indicated that the diabetes-related cardiovascular risk depends on a number of risk factors in diabetes mellitus [30], another study has shown that the degree of atherosclerosis is unrelated to the number of risk factors in diabetes [31]. There are important differences in the inclusion criteria of the study that also need to be addressed.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Changes in short- and long-term cardiovascular risk of incident diabetes and incident myocardial infarction—a nationwide study

et al. 2010

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Aims/hypothesis We assessed secular trends of cardiovascular outcomes following first diagnosis of myocardial infarction (MI) or diabetes in an unselected population. Methods All Danish residents aged ≥30 years without prior diabetes or MI were identified by individual-level linkage of nationwide registers. Individuals hospitalised with MI or claiming a first-time prescription for a glucose-lowering medication (GLM) during the period from 1997 to 2006 were included. Analyses were by Poisson regression models. Primary endpoints were death by all causes, cardiovascular death and MI. Results The study included 3,092,580 individuals, of whom 77,147 had incident MI and 118,247 new-onset diabetes. MI patients had an increased short-term risk of all endpoints compared with the general population. The rate ratio (RR) for cardiovascular death within the first year after MI was 11.1 (95% CI 10.8-11.5) in men and 14.8 (14.3-15.3) in women, respectively. The risk rapidly declined and 1 year after the index MI, RR was 2.11 (2.00-2.23) and 2.8 (2.64-2.97) in men and women, respectively. Patients with diabetes carried a constantly elevated risk of all endpoints compared with the general population. The cardiovascular death RR was 1.90 (1.77-2.04) and 1.92 (1.78-2.07) in men and women, respectively during the first year after GLM initiation. Conclusions/interpretation Incident MI is associated with high short-term risk, which decreases rapidly over time. Incident diabetes is associated with a persistent excessive cardiovascular risk after initiation of GLM therapy. This further strengthens the necessity of early multi-factorial intervention in diabetes patients for long-term benefit.

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“…Several studies of asymptomatic type 2 diabetic patients have specifically examined whether risk factor burden (i.e., number of risk factors) is predictive of inducible ischemia (as determined by myocardial perfusion imaging), and these have not supported the recommendation of the 1998 consensus panel for screening asymptomatic patients with two or more risk factors (12)(13)(14). At the same time, evidence has accumulated regarding newer CAD diagnostic modalities, e.g., CT angiography (15), coronary artery calcium scoring (16,17), and cardiac magnetic resonance imaging (18), that are being implemented in strategies to diagnose and stage CAD.…”

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confidence: 99%

“…The strategy of screening patients with diabetes for advanced asymptomatic CAD is motivated by the goal of identifying patients with high cardiac risk whose outcomes might be improved through more aggressive risk factor modification, medical surveillance, or revascularization of their CAD. However, clinical factors that confer risk for adverse cardiac outcomes do not always predict which patients will have abnormal screening tests (13,14), and negative screening tests in patients with diabetes do not uniformly confer a benign prognosis (20,21 (22). In middle-aged subjects with newly detected diet-controlled diabetes in the Diabetes Intervention Study, 15% had evidence of myocardial infarction by 11 years of follow-up (23).…”

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confidence: 99%

Screening for Coronary Artery Disease in Patients With Diabetes

et al. 2007

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Coronary artery disease (CAD) accounts for a large fraction of the morbidity, mortality, and cost of diabetes. Recognizing this, nearly 10 years ago the American Diabetes Association published a consensus recommendation that clinicians consider a risk factor–guided screening approach to early diagnosis of CAD in both symptomatic and asymptomatic patients. Subsequent clinical trial results have not supported those recommendations. Since the prior consensus statement, newer imaging methods, such as coronary artery calcium scoring and noninvasive angiography with computed tomography (CT) techniques, have come into use. These technologies, which allow quantitation of atherosclerotic burden and can predict risk of cardiac events, might provide an approach to more widespread coronary atherosclerosis screening. However, over this same time interval, there has been recognition of diabetes as a cardiovascular disease (CVD) equivalent, clear demonstration that medical interventions should provide primary and secondary CVD risk reduction in diabetic populations, and suggestive evidence that percutaneous coronary revascularization may not provide additive survival benefit to intensive medical management in patients with stable CAD. This additional evidence raises the question of whether documenting asymptomatic atherosclerosis or ischemia in people with diabetes is warranted. More data addressing this issue will be forthcoming from the BARI 2-D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. Until then, for patients with type 2 diabetes who are asymptomatic for CAD, we recommend that testing for atherosclerosis or ischemia, perhaps with cardiac CT as the initial test, be reserved for those in whom medical treatment goals cannot be met and for selected individuals in whom there is strong clinical suspicion of very-high-risk CAD. Better approaches to identify such individuals based on readily obtained clinical variables are sorely needed.

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Detection of Coronary Artery Disease in Asymptomatic Patients With Type 2 Diabetes Mellitus

Cited by 209 publications

References 33 publications

Role of Coronary CT Angiography in Asymptomatic Patients With Type 2 Diabetes Mellitus

Role of Coronary CT Angiography in Asymptomatic Patients With Type 2 Diabetes Mellitus

Changes in short- and long-term cardiovascular risk of incident diabetes and incident myocardial infarction—a nationwide study

Screening for Coronary Artery Disease in Patients With Diabetes

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