Incremental Predictive Value of Carotid Ultrasonography in the Assessment of Coronary Risk in a Cohort of Asymptomatic Type 2 Diabetic Subjects

Abstract

OBJECTIVE -Consensus guidelines recommend cardiovascular risk assessment as the initial step of primary prevention. The aim of this study was to evaluate the incremental predictive value for coronary events conferred by carotid ultrasonography in addition to risk assessment by Framingham score and screening for silent myocardial ischemia in a cohort of type 2 diabetic patients.RESEARCH DESIGN AND METHODS -We prospectively studied 229 patients free of any cardiovascular complication with at least one additional cardiovascular risk factor. At baseline, all patients had an exercise treadmill test, carotid intima-media thickness (IMT) measurement, and coronary risk assessment by Framingham score. Cardiovascular events were registered during a 5-year follow-up period.RESULTS -Age, carotid IMT, carotid plaques, number of risk factors, Framingham score, and suboptimal exercise electrocardiogram were associated with incident cardiovascular events (P Ͻ 0.05). Carotid IMT was an independent predictor of cardiovascular events (P ϭ 0.045). The predictive value for coronary events was similar for carotid IMT and Framingham score as assessed by area under the receiver operating characteristic curves. An improvement in risk prediction was conferred by addition of carotid IMT in a Cox model (global 2 increased from 14.1 to 18.1, P ϭ 0.035).CONCLUSIONS -This prospective study confirms that carotid IMT is a marker of cardiovascular risk in this type 2 diabetic cohort, establishes that carotid IMT provides a similar predictive value for coronary events than Framingham score, and suggests that the combination of these two indexes significantly improves risk prediction for these patients. Diabetes Care 28:1158 -1162, 2005C ardiovascular diseases are the main causes of death for diabetic patients (1). Coronary artery lesions are more extensive in diabetic patients, and coronary artery disease has a worse prognosis than in nondiabetic subjects (2). Moreover, silent myocardial ischemia, which is more frequent in diabetic patients than in the general population, can lead to delayed diagnosis and is associated with an increased risk of cardiac events (3-5).Therefore, a strategy to efficiently reduce coronary morbidity and mortality in this high-risk population implies the capability to identify patients with the highest potential of developing coronary events. American and European guidelines recommend an office-based assessment as the initial step in predicting risk in primary prevention (6,7). This determination of coronary risk can be performed by a multifactorial statistical model such as Framingham risk scoring. Screening for silent myocardial ischemia is recommended when two or more additional risk factors are present (8). An exercise electrocardiogram test is often the first-line screening procedure and can yield prognostic information in both asymptomatic diabetic and nondiabetic men (5,9). Myocardial scintigraphy or a stress echocardiogram is additionally recommended if the exercise test is suboptimal (6,7). However, their predi...

Relationship between cardiovascular risk factors and the echogenicity and pattern of the carotid intima-media complex in men

“…4,23 Knowing the intima-media thickness is considered to improve cardiovascular risk assessments particularly among patients with intermediate Framingham scores. 22 In type 2 diabetic patients, the extent of the carotid intimamedia complex can help predict coronary events in the same way as the Framingham score, but using these two indices together significantly improves the risk prediction. 23 Higher fasting glucose levels explained 28% of the increased thickness of the carotid intima-media complex in the patients with metabolic syndrome and about 3% of the change in echogenicity and intima-media pattern, in general.…”

“…21,22 Intimamedia thickness is widely used as a marker for early carotid atherosclerosis. 4,23 Knowing the intima-media thickness is considered to improve cardiovascular risk assessments particularly among patients with intermediate Framingham scores.…”

Long-Term Effects of Pioglitazone on Carotid Atherosclerosis in Japanese Patients with Type 2 Diabetes without a Recent History of Macrovascular Morbidity

“…Carotid ultrasound measurements of IMT are well-accepted predictors of CV events in subjects with and without type 2 diabetes 18,19) . Changes in carotid IMT over time correlate with future CV event rates 20) .…”

ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD – Summary

“…CAC and myocardial perfusion scintigraphy findings were synergistic for the prediction of cardiovascular events. 45 Ankle-brachial index (ABI), 46 carotid intimamedia thickness and detection of carotid plaques, 47 arterial stiffness by pulse wave velocity, 48 and cardiac autonomic neuropathy (CAN) by standard reflex tests may be considered as useful cardiovascular markers, 49 adding predictive value to the usual risk estimates. CAD is often silent in DM and up to 60% of myocardial infarction (MI) maybe asymptomatic, diagnosed by systematic electro-cardiogram (ECG) screening.…”