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Microalbuminuria predicts silent myocardial ischaemia in type 2 diabetes patients

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Abstract

Purpose

Myocardial ischaemia is frequently silent in patients with type 2 diabetes. Although it has been proposed as a potential screening tool, the role of myocardial perfusion single photon emission computed tomography (MPS) has recently been questioned, due to the low prevalence of positive scans and the low rate of cardiac events. The aim of this study was to assess if pretest clinical variables can identify a subgroup of asymptomatic patients with type 2 diabetes at risk of silent myocardial ischaemia and a subsequent poor outcome

Methods

This prospective study included 77 patients (50 men, mean age 63 ± 9 years) with type 2 diabetes and no known coronary artery disease (CAD) or angina pectoris who underwent gated MPS to screen for CAD between March 2006 and October 2008. MPS images were interpreted using a semiquantitative visual 20-segment model to define summed stress, rest and difference scores. Ischaemia was defined as a sum difference score (SDS) ≥2. Patients were followed-up (median 4.1 years, range 0.8 – 6.1 years) and cardiac hard events (cardiac death or nonfatal myocardial infarction) were recorded.

Results

Silent ischaemia was detected in 25 of the 77 patients (32 %). Specifically, 10 patients (13 %) had mild ischaemia (SDS 2 to ≤4) and 15 patients (19 %) had severe ischaemia (SDS >4). In univariate binary logistic analysis, microalbuminuria was the only significant predictor of silent ischaemia on MPS (odds ratio 4.42, 95 % CI 1.27 – 15.40; P = 0.019). The overall accuracy of microalbuminuria for predicting silent ischaemia was 71.4 % and was 89.6 % for predicting severe ischaemia. Kaplan-Meier curves showed no significant group differences in 5-year cardiac event-free survival between patients with and those without microalbuminuria, or between patients with SDS ≥2 and those with SDS <2. In contrast, 5-year event-free survival was significantly lower in patients with SDS >4 than in patients with SDS ≤4: 55.6 % (95 % CI 39.0 – 72.2 %) vs. 94.5 % (95 % CI: 91.4 – 97.6 %), respectively (Breslow test, chi-square 20.9, P < 0.001). Median cardiac event-free survival was not observed in the whole group, while the 25th percentile of cardiac event-free survival was reached only in patients with SDS >4 (2.3 years). In univariate Cox regression analysis, SDS >4 predicted cardiac event-free survival (hazard ratio 12.87, 95 % CI 2.86 – 27.98; P = 0.001), while SDS ≥2 did not (hazard ratio 2.78, 95 % CI 0.62 – 12.46, P = 0.16).

Conclusion

In this group of patients with type 2 diabetes, microalbuminuria was the only predictor of silent ischaemia on MPS. Assessment of microalbuminuria should be routinely considered among the first risk stratification steps for CAD in patients with type 2 diabetes, even though severe ischaemia on MPS is a major predictor of cardiac event-free survival.

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Authors and Affiliations

  1. Nuclear Medicine Department, S. Andrea Hospital, Via Vittorio Veneto, 197, 19124, La Spezia, Italy

    Giampiero Giovacchini, Mario Cappagli, Antonella Montepagani, Rossella Leoncini & Andrea Ciarmiello

  2. Department of Radiology, Stadtspital Triemli, Zurich, Switzerland

    Giampiero Giovacchini

  3. Department of Radiology and Nuclear Medicine, Stadtspital Waid, Zurich, Switzerland

    Giampiero Giovacchini

  4. Diabetes Center, S. Andrea Hospital, La Spezia, Italy

    Stefano Carro

  5. Cardiology Department, S. Andrea Hospital, La Spezia, Italy

    Sandro Borrini & Gianfranco Mazzotta

  6. Department of Internal Medicine, Nuclear Medicine Unit, University of Genoa Medical School, Genoa, Italy

    Gianmario Sambuceti

  7. Regional Center of Nuclear Medicine, University of Pisa Medical School, Pisa, Italy

    Giuliano Mariani & Duccio Volterrani

  8. Department of Cardiology, University Hospital Basel, Basel, Switzerland

    Michael J. Zellweger

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  1. Giampiero Giovacchini
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  2. Mario Cappagli
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Giovacchini, G., Cappagli, M., Carro, S. et al. Microalbuminuria predicts silent myocardial ischaemia in type 2 diabetes patients. Eur J Nucl Med Mol Imaging 40, 548–557 (2013). https://doi.org/10.1007/s00259-012-2323-5

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  • DOI: https://doi.org/10.1007/s00259-012-2323-5

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