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Coronary Computed Tomography Angiography for Screening in Patients with Diabetes: Can Enhanced Detection of Subclinical Coronary Atherosclerosis Improve Outcome?

Abstract

Purpose of Review

It is well known that there is a very high risk of cardiovascular complications among diabetic patients. In spite of all efforts at aggressive control of diabetes and its complications, the incidence of cardiovascular morbidity and mortality remains high, including in patients with no prior symptoms, underscoring a possible advantage for appropriate screening of asymptomatic patients for the presence of obstructive coronary artery disease (CAD). In this article, we sought primarily to review the results of studies designed to evaluate a possible role of coronary computed tomography angiography (CCTA) in the screening of asymptomatic diabetic patients for possible obstructive CAD.

Recent Findings

Our review of current literature indicates that there is still no method of CAD screening identified that has been shown to reduce the cardiovascular risk of asymptomatic diabetic patients. Therefore, the utility and value of screening for CAD in asymptomatic diabetic patients remains controversial. CCTA screening has shown promise and has been demonstrated to predict future risk, but as yet has not demonstrated improvement in the outcomes of these high-risk patients.

Summary

At our present state of knowledge, aggressive risk factor reduction appears to be the most important primary prevention strategy for all asymptomatic high-risk diabetic patients. However, there remains a great need for better and more sensitive and specific screening methods, as well as more effective treatments that may allow us to more accurately target diabetic patients who really are at high risk. Further large randomized and well-controlled clinical trials may be necessary to determine whether screening for CAD can reduce cardiovascular event rates in patients with diabetes.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Xu J, Murphy SL, Kochanek KD, Bastian BA. Deaths: final data for 2013. Natl Vital Stat Rep Natl Cent Health Stat. 2016;64(2):1–2.

    Google Scholar 

  2. Centers for Disease Control and Prevention. National Diabetes Statistics Report 2014: Estimates of Diabetes and Its Burden in the United States. Atlanta, GA: U.S. Department of Health and Human Services; 2014. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

  3. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28–292.

    Article  PubMed  Google Scholar 

  4. Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. 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;229(4):229–34.

    Article  Google Scholar 

  5. Tsujimoto T, Kajio H, Takahashi Y, Kishimoto M, Noto H, Yamamoto-Honda R, et al. Asymptomatic coronary heart disease in patients with type 2 diabetes with vascular complications: a cross-sectional study. BMJ Open. 2011;1, e000139.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Geiss LS, Herman WH, Smith PJ: Mortality in Non-Insulin Dependent Diabetes. Diabetes in America, 2nd Edition, National Institutes of Health 1995; 233-7.

  7. Portuese E, Orchard T: Mortality in Insulin Dependent Diabetes. Diabetes in America, 2nd Edition, National Institutes of Health 1995; 221-2.

  8. DPP (Diabetes Prevention Program). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393–403.

    Article  Google Scholar 

  9. Cefalu WT. American Diabetes Association, standards of medical care in diabetes—2016. Diabetes Care. 2016;39(1):S1–112. This paper provides, in a standardized way, guidelines and recommendations for management of patients with diabetes provided, in 2016, by the American Diabetes Association.

  10. The BARI 2D Study Group. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360(24):2503–15.

    Article  PubMed Central  Google Scholar 

  11. Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503–16.

    CAS  Article  PubMed  Google Scholar 

  12. Fox CS, Golden SH, Anderson C, Bray GA, Burke LE, De Boer IH, et al. Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence: a scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care. 2015;38(9):1777–803.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. Young LH, Wackers FJT, Chyun DA, Davey JA, Barrett EJ, Taillefer R, et al. Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes. The DIAD study: a randomized controlled trial. J Am Med Assoc. 2011;301(15):1547–55.

    Article  Google Scholar 

  14. The FIELD Study Investigators. Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised controlled trial. Lancet. 2005;366(9500):1849–61.

    Article  Google Scholar 

  15. The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):2545–59.

    Article  PubMed Central  Google Scholar 

  16. Muhlestein JB et al: INtermountain Healthcare Biological Samples Collection Project and Investigational REgistry for the On-going Study of Disease Origin, Progression and Treatment (INSPIRE) (unpublished registry data, on file).

  17. Mark DB, Berman DS, Budoff MJ, Carr JJ, Gerber TC, Hecht HS, et al. ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol. 2010;55(23):2663–99. This manuscript provides an expert group of cardiologists consensus opinion regarding the appropriate way to utilize coronary computed tomographic angiography in the management of patients at risk for coronary artery disease.

  18. Miller JM, Rochitte CE, Dewey M, Arbab-Zadeh A, Niinuma H, Gottlieb I, et al. Diagnostic performance of coronary angiography by 64-row CT. NEJM. 2008;359(22):2324–36. This manuscript provides a review of the published data regarding the performance of 64-row CT coronary angiography in determining the severity of coronary artery disease in patients.

  19. Arbab-Zadeh A, Miller JM, Rochitte CE, Dewey M, Niinuma H, Gottlieb I, et al. Diagnostic accuracy of computed tomography coronary angiography according to Pre-test probability of coronary artery disease and severity of coronary arterial calcification. The CORE-64 (coronary artery evaluation using 64-row multidetector computed tomography angiography) international multicenter study. J Am Coll Cardiol. 2012;59(4):379–87.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Nielsen LH, Ortner N, Nørgaard BL, Achenbach S, Leipsic J, Abdulla J. The diagnostic accuracy and outcomes after coronary computed tomography angiography vs. conventional functional testing in patients with stable angina pectoris: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging. 2014;15:961–71. This provides a meta-analysis of published data comparing the diagnostic accuracy and clinical outcomes associated with CT coronary angiography compared to conventional functional testing in patients with stable angina symptoms.

  21. McKavanagh P, Lusk L, Ball PA, Verghis RM, Agus AM, Trinick TR, et al. A comparison of cardiac computerized tomography and exercise stress electrocardiogram test for the investigation of stable chest pain: the clinical results of the CAPP randomized prospective trial. Eur Heart J Cardiovasc Imaging. 2015;16:441–8.

    CAS  Article  PubMed  Google Scholar 

  22. Muhlestein JB, Lappe DL, Lima JAC, Rosen BD, May HT, Knight S, et al. Effect of screening for coronary artery disease using CT angiography on mortality and cardiac events in high-risk patients with diabetes. The FACTOR-64 randomized clinical trial. J Am Med Assoc. 2014;312(2):2234–43. This manuscript provides the long-term clinical outcomes of 900 asymptomatic high risk diabetic patients who were randomized to standard care versus screening for underlying coronary artery disease by CT coronary angiography.

  23. Douglas PS, Hoffmann U, Patel MR, Mark DB, Al-Khalidi HR, Cavanaugh B, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372(14):1291–300.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  24. Hoffmann U, Truong QA, Schoenfeld DA, Chou ET, Woodard PK, Nagurney JT, et al. Coronary CT angiography versus standard evaluation in acute chest pain. NEJM. 2012;367(4):299–308.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  25. Truong QA, Schulman-Marcus J, Zakroysky P, Chou ET, Nagurney JT, Fleg JL, et al. Coronary CT Angiography Versus Standard Emergency Department Evaluation for Acute Chest Pain and Diabetic Patients: Is There Benefit With Early Coronary CT Angiography? Results of the Randomized Comparative Effectiveness ROMICAT II Trial. Journal of the American Heart Association 2016; 5:e003137 doi:10.1161/JAHA.115.003137.

  26. Turrini F, Scarlini S, Mannucci C, Messora R, Giovanardi P, Magnavacchi P, et al. Does coronary atherosclerosis deserve to be diagnosed early in diabetic patients? The DADDY-D trial. Screening diabetic patients for unknown coronary disease. Eur J Intern Med. 2015;26:407–13.

    Article  PubMed  Google Scholar 

  27. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA, Coronary Revascularization Writing Group. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2012;59(9):857–81.

    Article  PubMed  Google Scholar 

  28. Tonino PAL, De Bruyne BD, Pijls NHJ, Siebert U, Keno F, Van’t Veer M, et al. Fractional flow reserve versus angiography for guiding percutneous coronary intervention. N Engl J Med. 2009;360(3):213–24.

    CAS  Article  PubMed  Google Scholar 

  29. De Bruyne BD, Pijls NHJ, Kalesan B, Barbato E, Tonino PAL, for the FAME 2 Trial Investigators, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 2012;367(11):991–1001.

    Article  PubMed  Google Scholar 

  30. Taylor CA, Fonte TA, Min JK. Computational fluid dynamics applied to cardiac computed tomography for noninvasive quantification of fractional flow reserve. Scientific basis. J Am Coll Cardiol. 2013;61(22):2233–41.

    Article  PubMed  Google Scholar 

  31. Min JK, Taylor CA, Achenbach S, Koo BK, Leipsic J, Norgaard BL, et al. Noninvasive fractional flow reserve derived from coronary CT angiography. Clinical data and scientific principles. J Am Coll Cardiol Img. 2015;8(10):1209–22.

    Article  Google Scholar 

  32. Kwan AC, May HT, Cater G, Sibley CT, Rosen BD, Lima JAC, et al. Coronary artery plaque volume and obesity in patients with diabetes: the Factor-64 study. Radiology. 2014;272(3):690–9.

    Article  PubMed  PubMed Central  Google Scholar 

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Correspondence to Joseph Brent Muhlestein.

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Joseph Brent Muhlestein and Fidela Ll. Moreno declare that they have no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Clinical Trials and Their Interpretations

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Muhlestein, J.B., Moreno, F.L. Coronary Computed Tomography Angiography for Screening in Patients with Diabetes: Can Enhanced Detection of Subclinical Coronary Atherosclerosis Improve Outcome?. Curr Atheroscler Rep 18, 64 (2016). https://doi.org/10.1007/s11883-016-0620-3

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  • DOI: https://doi.org/10.1007/s11883-016-0620-3

Keywords

  • Coronary artery disease
  • CAD
  • Diabetes
  • CAD screening
  • Coronary computed tomography angiography
  • CCTA