Silent myocardial ischemia in patients with non-insulin-dependent diabetes mellitus as judged by treadmill exercise testing and coronary angiography

Naka, Motoji; Hiramatsu, Kohzy; Aizawa, Toru; Momose, Atsushi; Yoshizawa, Kunio; Shigematsu, Satoshi; Ishihara, Fujiki; Niwa, Akira; Yamada, Takashi

doi:10.1016/0002-8703(92)90745-h

Cited by 127 publications

(72 citation statements)

References 26 publications

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“…The positive predictive value of bicycle exercise ECG was 63 %, a percentage which according to the Bayes' theorem [23] may have been due to the prevalence of CAD in this population. This result is in agreement with the results previously reported in asymptomatic diabetic patients [9,11,24]. The negative predictive value of 86 % strongly supports the use of the ECG exercise test as the first step in the clinical investigation of diabetic patients, because a negative maximal exercise test is very likely to exclude the diagnosis of CAD in such a population.…”

Section: Discussionsupporting

confidence: 91%

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Detection of coronary artery disease in diabetic patients

et al. 1995

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SummaryCoronary artery disease may be difficult to detect in diabetic patients. This study was designed to determine the specificity and sensitivity of three noninvasive tests. Accordingly, the results of 48-h ambulatory electrocardiogram (ECG) monitoring, maximal ECG exercise test, and intravenous dipyridamole myocardial thallium scintigraphy were compared in 59 middle-aged diabetic patients who were consecutively selected for suspected coronary artery disease. All patients also underwent coronary angiography, which was performed regardless of the results of the non-invasive tests. Twenty patients (34 %) had significant coronary lesions, i.e. stenosis equal to or greater than 70 %, and 16 of these 20 patients (80 %) had double or triple vessel disease. Sensitivity and specificity were, respectively, 25 % and 88 % for ambulatory ECG monitoring, 75 % and 77 % for the exercise test and 80 % and 87 % for thallium myocardial scintigraphy. This observation strongly supports the use of non-invasive tests for the detection of coronary artery disease in those diabetic patients at high risk of such disease. As the exercise test is cheaper and more widely available than thallium myocardial scintigraphy it should be used as a first line examination. Dipyridamole myocardial scintigraphy may provide an alternative solution for those patients who cannot perform maximal exercise, or with atypical clinical presentation. [Diabetologia (1995) 38: 726-731] Key words Non-invasive test, detection, coronary artery disease, diabetic patients.Large epidemiological prospective studies have shown that coronary artery disease (CAD) is the main cause of morbidity and death in patients with diabetes mellitus [1][2][3]. Recently, the Multiple Risk Factor Intervention Trial (MRFIT) [4] reported that the mortality rate for CAD and cardiovascular disease was three times higher in diabetic men than in non-diabetic men. Furthermore, a significant independent association between diabetes and cardiovascular mortality was definitively demonstrated in this trial.

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Section: Discussionsupporting

confidence: 91%

“…Thus, it has repeatedly been suggested that silent myocardial ischaemia, which has a poor prognosis and sometimes reveals the presence of severe CAD, is more frequent among these populations [6][7][8][9][10][11][12].…”

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confidence: 99%

Detection of coronary artery disease in diabetic patients

et al. 1995

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“…16 Diabetic patients who are treadmill-positive often have a prevalence of silent myocardial ischemia. 17 The BARI study 18 reported highly significant improved survival in patients with treated diabetes and multivessel disease who underwent CABG; however, the benefits of CABG were restricted only to patients receiving at least 1 arterial conduit during CABG. Both BARI 1 and EAST 19 studies enrolled symptomatic patients with multivessel patients undergoing CABG, but the numbers of patients with treated diabetes were small.…”

Section: Endo Et Al Bilateral Imas For Diabetes 1347mentioning

confidence: 99%

Bilateral Versus Unilateral Internal Mammary Revascularization in Patients With Diabetes

2003

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Background-This historical cohort study evaluated the benefit of bilateral internal mammary artery (BIMA) grafts in coronary bypass grafting (CABG) for patients with diabetes. Methods and Results-We performed elective, isolated, primary, multiple CABG using skeletonized internal mammary artery (IMA) grafts for multivessel disease in 1131 patients, 467 (41.3%) of whom had type 2 diabetes mellitus. The early and long-term results were compared between 277 patients with diabetes using single IMA (SIMA) grafts and 190 using BIMA grafts (median follow-up, 8.1 years). Hospital mortality was similar in both groups. Early patency rate of all grafts was significantly higher using BIMA than using SIMA (97.7% versus 93.8%, Pϭ0.0012). Survival rates were not significantly different between SIMA and BIMA groups. Late cardiac mortality was significantly higher in patients with low ejection fraction (0.4 or lower) compared with preserved ejection fraction (higher than 0.4) (Pϭ0.0001). In patients with preserved ejection fraction, 10-year survival rate was significantly higher using BIMA than using SIMA (87.8Ϯ3.5% versus 75.2Ϯ3.4%, Pϭ0.04), and 10-year all death-free or repeat CABG or recurrent myocardial infarction-free rate was significantly higher using BIMA than using SIMA (86.6Ϯ3.6% versus 69.0Ϯ3.7%, Pϭ0.0086).The hazard ratio for all death or repeated CABG or recurrent myocardial infarction in patients with preserved ejection fraction was markedly lower in the BIMA group (0.53; 95% CI, 0.31 to 0.9; Pϭ0.019). Conclusions-Skeletonized

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“…any studies have investigated the presence of unknown asymptomatic coronary heart disease (CHD) among diabetic subjects (1)(2)(3)(4)(5)(6)(7). Each of these studies has shown, with different rates depending on the diagnostic methods and selection criteria used, increased prevalence rates compared with the general population.…”

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Cardiac Events in 735 Type 2 Diabetic Patients Who Underwent Screening for Unknown Asymptomatic Coronary Heart Disease

et al. 2002

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OBJECTIVE -To report the cardiac events in type 2 diabetic outpatients screened for unknown asymptomatic coronary heart disease (CHD) and followed for 5 years.RESEARCH DESIGN AND METHODS -During 1993, 925 subjects aged 40 -65 years underwent an exercise treadmill test (ETT). If it was abnormal, the subjects then underwent an exercise scintigraphy. Of the 925 subjects, 735 were followed for 5 years and cardiac events were recorded.RESULTS -At the entry of the study, 638 of the 735 followed subjects had normal ETT, 45 had abnormal ETT with normal scintigraphy, and 52 had abnormal ETT and abnormal scintigraphy. The 52 subjects with abnormal scintigraphy and ETT underwent a cardiological and diabetological follow-up; the subjects with just abnormal ETT had a diabetological follow-up only. During the follow-ups, 42 cardiac events occurred: 1 fatal myocardial infarction (MI), 20 nonfatal MIs, and 10 cases of angina in the 638 subjects with normal ETT; 1 fatal MI in the 45 subjects with normal scintigraphy; and 1 fatal MI and 9 cases of angina in the 52 subjects with abnormal scintigraphy. In these 52 subjects all cardiac events were significantly more frequent ( 2 ϭ 21.40, P Ͻ 0.0001) but the ratio of major (cardiac death and MI) to minor (angina) cardiac events was significantly lower (P ϭ 0.002). Scintigraphy abnormality (hazard ratio 5.47; P Ͻ 0.001; 95% CI 2.43-12.29), diabetes duration (1.06; P ϭ 0.021; 1.008 -1.106), and diabetic retinopathy (2.371; P ϭ 0.036; 1.059 -5.307) were independent predictors of cardiac events on multivariate analysis. CONCLUSIONS -The low ratio of major to minor cardiac events in the positive scintigraphy group may suggest, although it does not prove, that the screening program followed by appropriate management was effective for the reduction of risk of major cardiac events.

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Silent myocardial ischemia in patients with non-insulin-dependent diabetes mellitus as judged by treadmill exercise testing and coronary angiography

Cited by 127 publications

References 26 publications

Detection of coronary artery disease in diabetic patients

Detection of coronary artery disease in diabetic patients

Bilateral Versus Unilateral Internal Mammary Revascularization in Patients With Diabetes

Cardiac Events in 735 Type 2 Diabetic Patients Who Underwent Screening for Unknown Asymptomatic Coronary Heart Disease

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