Prevention Conference VI: Diabetes and Cardiovascular Disease

Redberg, Rita F.; Greenland, Philip; Fuster, Valentı́n; Pyörälà, Kalevi; Blair, Steven N.; Folsom, Aaron R.; Newman, Anne B.; O’Leary, Daniel H.; Orchard, Trever J.; Psaty, Bruce M.; Schwartz, J. Sanford; Starke, Rodman D.; Wilson, Peter W.F.

doi:10.1161/01.cir.0000013955.34262.af

Cited by 75 publications

(14 citation statements)

References 90 publications

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“…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.…”

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confidence: 99%

“…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 predictive value is somewhat disappointing because the sensitivities of all these screening stress tests are low in asymptomatic populations (3).…”

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

et al. 2005

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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...

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

et al. 2005

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“…However, absolute CHD risk varies within the diabetic population and further risk stratification might help in making clinical decisions about aggressiveness of preventive management. The recent American Heart Association's Prevention Conference VI reviewed various means beyond basic risk factor assessment to accomplish CHD risk assessment in diabetic patients (6). However, epidemiological data on the value of novel markers of CHD risk in people with diabetes were scarce.…”

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Prediction of Coronary Heart Disease in Middle-Aged Adults With Diabetes

Chambless²,

et al. 2003

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OBJECTIVE -To determine the 10-year probability of coronary heart disease (CHD) in diabetic adults and how well basic and novel risk factors predict CHD risk.RESEARCH DESIGN AND METHODS -We measured risk factors in 14,054 participants (1,500 with diabetes) initially free of CHD in the Atherosclerosis Risk in Communities study from 1987 to 1989 and followed them prospectively for CHD incidence through 1998. We used proportional hazards regression models and receiver operating characteristic (ROC) curves for CHD risk prediction.RESULTS -Based on our model using basic risk factors (age, race, total and HDL cholesterol, systolic blood pressure, antihypertensives, and smoking status), ϳ61% of diabetic women and 86% of diabetic men had a predicted 10-year CHD probability Ն10%. This CHD risk-prediction model had an area under the ROC curve of 0.72 in diabetic women and 0.67 in diabetic men. Novel risk factors or subclinical disease markers individually added only modest predictivity, but the addition of multiple markers (BMI, waist-to-hip ratio, Keys dietary score, serum albumin and creatinine, factor VIII, white blood cell count, left ventricular hypertrophy determined by electrocardiogram, and carotid intima-media thickness) increased the area under the curve by ϳ10%.CONCLUSIONS -Although all diabetic adults are at high risk for CHD, their variation in CHD risk can be predicted moderately well by basic risk factors. No single novel risk marker greatly enhanced absolute CHD risk assessment, but a battery of novel markers did. Our model can provide estimates of CHD risk for the primary prevention of this disease in people with type 2 diabetes. Diabetes Care 26:2777-2784, 2003U sing multivariable risk assessment to define the likelihood of a coronary heart disease (CHD) event has become a cornerstone of preventive cardiology. The Framingham Study provided the most widely used CHD risk equation (1), which generalizes fairly well to other healthy populations (2). The Framingham model includes a variable for diabetes status (yes/no), but the U.K. Prospective Diabetes Study recently provided a multivariable CHD risk equation specifically for people with diabetes (3).People with diabetes are at particularly high risk of CHD, so much so that the National Cholesterol Education Program (NCEP) now recommends that diabetic patients do not need specific CHD risk assessment, but instead that they be managed as if they had CHD (4). Likewise, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) recommends that hypertension be aggressively managed in diabetic patients (5). However, absolute CHD risk varies within the diabetic population and further risk stratification might help in making clinical decisions about aggressiveness of preventive management. The recent American Heart Association's Prevention Conference VI reviewed various means beyond basic risk factor assessment to accomplish CHD risk assessment in diabetic patients (6). However, epidemiological data on the value of...

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“…The guideline also stated that exercise treadmill testing in general "might be useful in people with heightened pretest risk." 6,7 Other tests to consider include high-sensitivity C-reactive protein (CRP), electron-beam computed tomography, measurement of ankle-brachial index, and ultrasound to measure carotid intima-media thickness. 8,9 Data suggest that the CRP level is a stronger predictor of cardiovascular events than the LDL cholesterol level and that it adds prognostic information to that conveyed by the Framingham risk score.…”

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A 52-Year-Old Woman With Hypertension and Diabetes Who Presents With Chest Pain

Harris¹

2007

Clinical Diabetes

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Prevention Conference VI: Diabetes and Cardiovascular Disease

Cited by 75 publications

References 90 publications

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

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

Prediction of Coronary Heart Disease in Middle-Aged Adults With Diabetes

A 52-Year-Old Woman With Hypertension and Diabetes Who Presents With Chest Pain

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