Screening Asymptomatic Patients with Type 2 Diabetes Mellitus for Coronary Artery Disease: Does It Improve Patient Outcome?
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The increasing global burden, the reported high prevalence of rapidly progressive coronary artery disease (CAD), and the atypical nature of CAD presentation in type 2 diabetes mellitus have encouraged development of strategies for detecting occult CAD in this population. Several recent prospective studies have addressed the value of screening for CAD in asymptomatic diabetic patients. The overall message of these studies is that despite detection of silent ischemia in a notable proportion of these patients, the dynamic nature of myocardial ischemia, the prohibitive cost of screening all asymptomatic patients, and the proven efficacy of primary preventive strategies would mandate implementation of better clinical risk stratification strategies for identifying at-risk individuals. Questions still remain as to what best strategy would allow proper patient selection through logical stepwise approaches to screening and whether that would alter patients’ outcome when added to rigorously implemented primary preventive measures.
- King H, Aubert RE, Herman WH: Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections. Diabetes Care 1998, 21:1414–1431. CrossRef
- Bonow RO, Gheorghiade M: The diabetes epidemic: a national and global crisis. Am J Med 2004, 116:2–10. CrossRef
- Haffner SM, Lehto S, Ronnemaa T, et al.: Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998, 339:229–234. CrossRef
- Wild S, Roglic G, Green A, et al.: Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004, 27:1047–1053. CrossRef
- • Lloyd-Jones D, Adams R, Carnethon M, et al.: Heart Disease and Stroke Statistics—2009 Update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009, 119:e21–e181. These are annually updated comprehensive cardiovascular statistics in the United States. CrossRef
- Mokdad AH, Ford ES, Bowman BA, et al.: Prevalence of obesity, diabetes, and obesity-related health risk factors. JAMA 2003, 289:76–79. CrossRef
- Narayan KM, Boyle JP, Geiss LS, et al.: Impact of recent increase in incidence on future diabetes burden: United States 2005-2050. Diabetes Care 2006, 29:2114–2116. CrossRef
- Franco OH, Steyerberg EW, Hu FB, et al.: Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease. Arch Intern Med 2007, 167:1145–1151. CrossRef
- Ford ES, Ajani UA, Croft JB, et al.: Explaining the decrease in U.S. deaths from coronary disease, 1980–2000. N Engl J Med 2007, 356:2388–2398. CrossRef
- • White NH, Sun W, Cleary PA, et al.: Prolonged effect of intensive therapy on the risk of retinopathy complications in patients with type 1 diabetes mellitus: 10 years after the Diabetes Control and Complications Trial. Arch Ophthalmol 2008, 126:1707–1715. This is a major clinical study of 1441 type 1 diabetic patients (1983–1993) that showed marked improvement in microvascular and macrovascular complications through intensive control of blood sugar. CrossRef
- Intensive diabetes treatment and cardiovascular disease in type 1 diabetes mellitus. The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group [no authors listed]. N Engl J Med 2005, 353:2643–2653.
- Gerstein HC, Miller ME, Byington RP, et al.: Effects of intensive glucose lowering in type 2 diabetes (ACCORD Study). N Engl J Med 2008, 358:2545–2559. CrossRef
- Patel A, MacMahon S, Chalmers J, et al.: Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes (ADVANCE Trial). N Engl J Med 2008, 358:2560–2572. CrossRef
- •• Duckworth W, Abraira C, Moritz T, et al.: Glucose control and vascular complications in veterans with type 2 diabetes (VADT Investigators). N Engl J Med 2009, 360:129–139. This is one of the three major clinical trials (Gerstein et al.  and Patel et al. ) that showed no outcome benefit for intense glycemic control in type 2 DM. It also showed that very intense glycemic control (to normalized values of hemoglobin A 1c ) may be associated with increased mortality, especially in those with pre-existing CAD. CrossRef
- Holman RR, Paul SK, Bethel MA, et al.: 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008, 359:1577–1589. CrossRef
- Redberg RF, Benjamin EJ, Bittner V, et al.: ACCF/AHA 2009 performance measures for primary prevention of cardiovascular disease in adults. Circulation 2009, 120:1296–1336. CrossRef
- Dagenais GR, St-Pierre A, Gilbert P, et al.: Comparison of prognosis for men with type 2 diabetes mellitus and men with cardiovascular disease. CMAJ 2009, 180:40–47.
- Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): final report. US Department of Health and Human Services; Public Health Service; National Institutes of Health; National Heart, Lung, and Blood Institute [no authors listed]. Circulation 2002, 106:3143–3421.
- De Backer G, Ambrosioni E, Borch-Johnsen K, et al.: European guidelines on cardiovascular disease prevention in clinical practice: third joint task force of European and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of eight societies and by invited experts). Eur Heart J 2003, 24:1601–1610. CrossRef
- Goraya TY, Leibson CL, Palumbo PJ, et al.: Coronary atherosclerosis in diabetes mellitus: a population-based autopsy study. J Am Coll Cardiol 2002, 40:946–953. CrossRef
- Koistinen MJ: Prevalence of asymptomatic myocardial ischemia in diabetic subjects. BMJ 1990, 301:92–95. CrossRef
- Vanzetto G, Halimi S, Hammond T, et al.: Prediction of cardiovascular events in clinically selected high-risk NIDDM patients: prognostic value of exercise stress test and thallium-201 single-photon emission computed tomography. Diabetes Care 1999, 22:19–26. CrossRef
- Janand-Delenne B, Savin B, Habib G, et al.: Silent myocardial ischemia in patients with diabetes. Who to screen? Diabetes Care 1999, 22:1396–1400. CrossRef
- DeLorenzo A, Lima RS, Sequeira-Filho AG, Pantoja MR: Prevalence and prognostic value of perfusion defects detected by stress technetium-99 m sestamibi myocardial perfusion single-proton emission computed tomography in asymptomatic patients with diabetes mellitus and no known coronary artery disease. Am J Cardiol 2002, 90:827–832. CrossRef
- Zellweger MJ, Hachammovitch R, Kang X, et al.: Prognostic relevance of symptoms versus objective evidence of coronary artery disease in diabetic patients. Eur Heart J 2004, 25:543–550. CrossRef
- Rajagopalan N, Miller TD, Hodge DO, et al.: Identifying high-risk asymptomatic diabetic patients who are candidates for screening stress single-photon emission computed tomographic imaging. J Am Coll Cardiol 2005, 45:43–49. CrossRef
- Scholte AJ, Schuijf JD, Kharagjitsingh AV, et al.: Prevalence of coronary artery disease and plaque morphology assessed by multi-slice computed tomography coronary angiography and calcium scoring in asymptomatic patients with type 2 diabetes. Heart 2008, 94:290–295. CrossRef
- Prevalence of unrecognized silent myocardial ischemia and its association with atherosclerotic risk factors in noninsulin-dependent diabetes mellitus. Milan Study on Atherosclerosis and Diabetes (MiSAD) group [no authors listed]. Am J Cardiol 1997, 79:134–139.
- Faglia E, Favales F, Calia P, et al.: Cardiac events in 735 type 2 diabetic patients who underwent screening for unknown asymptomatic coronary heart disease: 5 year follow-up report from the Milan Study on Atherosclerosis in Diabetes (MiSAD). Diabetes Care 2002, 25:2032–2036. CrossRef
- Anand DV, Lim ETS, Hopkins D, et al.: Risk stratification in uncomplicated type 2 diabetes: prospective evaluation of the combined use of coronary artery calcium imaging and selective myocardial perfusion scintigraphy. Eur Heart J 2006, 27:713–721. CrossRef
- Wackers FJ, Young LH, Inzucchi SE, et al.: Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study. Diabetes Care 2004, 27:1954–1961. CrossRef
- Wackers FJ, Chyun DA, Young LH, et al.: Resolution of asymptomatic myocardial ischemia in patients with type 2 diabetes in the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study. Diabetes Care 2007, 30:892–898. CrossRef
- Young LH, Wackers FJ, Chyun DA, et al.: Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study: a randomized controlled trial. JAMA 2009, 301:1547–1555. CrossRef
- • Xu J, Zou MH: Molecular insights and therapeutic targets for diabetic endothelial dysfunction. Circulation 2009, 120:1266–1286. This is a comprehensive and authoritative review of the molecular basis of vascular endothelial dysfunction in DM. CrossRef
- Buse JB, Ginsberg HH, Bakris GL, et al.: Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation 2007, 115:114–126. CrossRef
- Diamond GA, Kaul S, Shah PK: Screen testing cardiovascular prevention in asymptomatic diabetic patients. J Am Coll Cardiol 2007, 49:1915–1917. CrossRef
- •• A randomized trial of therapies for type 2 diabetes and coronary artery disease. The BARI 2D Study Group [no authors listed]. N Engl J Med 2009, 360:2503–2515. This is the long-awaited results of a randomized trial of 2368 diabetic patients with CAD that showed no difference in the rate of death or major cardiovascular events in medically treated compared with revascularized patients.
- • Wiersma JJ, Verberne HJ, ten Holt WL, et al.: Prognostic value of myocardial perfusion scintigraphy in type 2 diabetic patients with mild, stable angina pectoris. J Nucl Cardiol 2009, 16:524–532. This is a post hoc analysis of myocardial perfusion imaging in 319 diabetic patients with mild anginal symptoms enrolled in the MERIDIAN trial. The presence of large perfusion defects was associated with a three- to sixfold increase in adverse cardiovascular event rates. CrossRef
- • Akalin S, Berntorp K, Ceriello A, et al.: Intensive therapy and clinical implications of recent data: a consensus statement from the Global Task Force on Glycemic Control. Int J Clin Pact 2009, 63:1421–1425. This is a position statement arguing for the value of glycemic control in type 2 DM despite the discouraging results of the ADVANCE, ACCORD, and VADT trials. CrossRef
- Gazzaruso C, Garzaniti A, Falcone C, et al.: Assessment of asymptomatic coronary artery disease in apparently uncomplicated type 2 diabetic patients. Diabetes Care 2002, 25:1418–1424. CrossRef
- Eggleston KN, Shah ND, Smith SA, et al.: The net value of health care for patients with type 2 diabetes, 1997 to 2005. Ann Intern Med 2009, 151:386–393.
- Screening Asymptomatic Patients with Type 2 Diabetes Mellitus for Coronary Artery Disease: Does It Improve Patient Outcome?
Current Cardiology Reports
Volume 12, Issue 2 , pp 140-146
- Cover Date
- Print ISSN
- Online ISSN
- Current Science Inc.
- Additional Links
- Coronary artery disease
- Diabetes mellitus
- Detection of ischemia in asymptomatic diabetes (DIAD)
- Myocardial perfusion imaging
- Industry Sectors
- Author Affiliations
- 1. Department of Cardiology, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA, 17822-2160, USA
- 2. Department of Diagnostic Radiology and Nuclear Medicine, The University of Maryland Hospital and School of Medicine, Gudelsky Building, Room N2W78, 22 South Greene Street, Baltimore, MD, 21201, USA