Skip to main content

Advertisement

Log in

Subclinical Cardiovascular Disease Assessment in Persons with Diabetes

  • Diabetes and Cardiovascular Disease (S Malik, Section Editor)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Patients with diabetes mellitus are at particularly high risk for cardiovascular disease. Although global risk factor scoring systems, such as the Framingham Risk Score, are well established for screening asymptomatic adults, they are not as predictive in diabetics. Therefore, there has been considerable interest in new screening tests to establish cardiovascular risk in diabetics. Coronary artery calcium assessment, both baseline levels and progression, have been shown to be additive to risk factor scoring systems and are independently predictive of cardiovascular mortality in diabetics. Current American Heart Association/American College of Cardiology Foundation guidelines recommend coronary calcium scoring for asymptomatic diabetics. Myocardial perfusion studies are recommended for patients with a coronary calcium score >400 but the level of evidence is poor. The data for other screening tests is limited. Further research is required into assessing what would be an appropriate follow-up duration for serial coronary calcium scanning.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

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

  1. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2–e220.

    Article  PubMed  Google Scholar 

  2. Meigs JB, Cupples LA, Wilson PW. Parental transmission of type 2 diabetes: the Framingham offspring study. Diabetes. 2000;49:2201–7.

    Article  PubMed  CAS  Google Scholar 

  3. National Diabetes Information Clearinghouse. Diabetes across the United States. Accessed at http://www2.niddk.nih.gov/populations/index.htm. Accessed Dec 2012.

  4. Centers for Disease Control and Prevention. National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: Department Of Health and Human Services, Centers for Disease Control and Prevention; 2011. Accessed Dec 2012.

  5. Narayan KM, Boyle JP, Geiss LS, Saaddine JB, Thompson TJ. Impact of recent increase in incidence on future diabetes burden: U.S., 2005–2050. Diabetes Care. 2006;29:2114–6.

    Article  PubMed  Google Scholar 

  6. D’Agostino RB, Russell MW, Huse DM, Ellison RC, Silbershatz H, Wilson PW, et al. Primary and subsequent coronary risk appraisal: new results from the Framingham study. Am Heart J. 2000;139:272–81.

    Article  PubMed  Google Scholar 

  7. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: Part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation. 2001;104:2746–53.

    Article  PubMed  CAS  Google Scholar 

  8. Ni H, Coady S, Rosamond W, Folsom AR, Chambless L, Russell SD, et al. Trends from 1987 to 2004 in sudden death due to coronary heart disease: the Atherosclerosis Risk in Communities (ARIC) study. Am Heart J. 2009;157:46–52.

    Article  PubMed  Google Scholar 

  9. Culic V, Eterovic D, Miric D, Silic N. Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors. Am Heart J. 2002;144:1012–7.

    Article  PubMed  Google Scholar 

  10. Hlatky MA, Greenland P, Arnett DK, Ballantyne CM, Criqui MH, Elkind MS, et al. Criteria for evaluation of novel markers of cardiovascular risk: a scientific statement from the American Heart Association. Circulation. 2009;119:2408–16.

    Article  PubMed  Google Scholar 

  11. Pencina MJ, D’Agostino Sr RB, D’Agostino Jr RB, Vasan RS. Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med. 2008;27:157–72. discussion 207–12.

    Article  PubMed  Google Scholar 

  12. Stevens RJ, Kothari V, Adler AI, Stratton IM. The UKPDS risk engine: a model for the risk of coronary heart disease in Type II diabetes (UKPDS 56). Clin Sci. 2001;101:671–9.

    Article  PubMed  CAS  Google Scholar 

  13. Assmann G, Cullen P, Schulte H. Simple scoring scheme for calculating the risk of acute coronary events based on the 10-year follow-up of the prospective cardiovascular Munster (PROCAM) study. Circulation. 2002;105:310–5.

    Article  PubMed  Google Scholar 

  14. Conroy RM, Pyorala K, Fitzgerald AP, Sans S, Menotti A, De Backer G, et al. Estimation of 10-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J. 2003;24:987–1003.

    Article  PubMed  CAS  Google Scholar 

  15. D’Agostino Sr RB, Grundy S, Sullivan LM, Wilson P. Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation. JAMA. 2001;286:180–7.

    Article  PubMed  Google Scholar 

  16. •• Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2010;122:2748–64. This recent paper presents guidelines for the assessment of asymptomatic adults, with a detailed section for asymptomatic diabetics.

    Article  PubMed  Google Scholar 

  17. Grover SA, Lowensteyn I, Esrey KL, Steinert Y, Joseph L, Abrahamowicz M. Do doctors accurately assess coronary risk in their patients? Preliminary results of the coronary health assessment study. BMJ. 1995;310:975–8.

    Article  PubMed  CAS  Google Scholar 

  18. Montgomery AA, Fahey T, MacKintosh C, Sharp DJ, Peters TJ. Estimation of cardiovascular risk in hypertensive patients in primary care. Br J Gen Pract. 2000;50:127–8.

    PubMed  CAS  Google Scholar 

  19. Friedmann PD, Brett AS, Mayo-Smith MF. Differences in generalists’ and cardiologists’ perceptions of cardiovascular risk and the outcomes of preventive therapy in cardiovascular disease. Ann Intern Med. 1996;124:414–21.

    Article  PubMed  CAS  Google Scholar 

  20. Gaziano TA, Young CR, Fitzmaurice G, Atwood S, Gaziano JM. Laboratory-based vs nonlaboratory-based method for assessment of cardiovascular disease risk: the NHANES I Follow-up Study cohort. Lancet. 2008;371:923–31.

    Article  PubMed  Google Scholar 

  21. Prediction of mortality from coronary heart disease among diverse populations: is there a common predictive function? Heart. 2002;88:222–8.

  22. Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, et al. Heart disease and stroke statistics—2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008;117:e25–146.

    Article  PubMed  Google Scholar 

  23. Coleman RL, Stevens RJ, Retnakaran R, Holman RR. Framingham, SCORE, and DECODE risk equations do not provide reliable cardiovascular risk estimates in type 2 diabetes. Diabetes Care. 2007;30:1292–3.

    Article  PubMed  Google Scholar 

  24. Lau KK, Wong YK, Chan YH, Yiu KH, Teo KC, Li LS, et al. Prognostic implications of surrogate markers of atherosclerosis in low to intermediate risk patients with type 2 Diabetes. Cardiovasc Diabetol. 2012;11:101.

    Article  PubMed  Google Scholar 

  25. McEwan P, Williams JE, Griffiths JD, Bagust A, Peters JR, Hopkinson P, et al. Evaluating the performance of the Framingham risk equations in a population with diabetes. Diabet Med. 2004;21:318–23.

    Article  PubMed  CAS  Google Scholar 

  26. van der Heijden AA, Ortegon MM, Niessen LW, Nijpels G, Dekker JM. Prediction of coronary heart disease risk in a general, pre-diabetic, and diabetic population during 10 years of follow-up: accuracy of the Framingham, SCORE, and UKPDS risk functions: the Hoorn study. Diabetes Care. 2009;32:2094–8.

    Article  PubMed  Google Scholar 

  27. Nasir K, Raggi P, Rumberger JA, Braunstein JB, Post WS, Budoff MJ, et al. Coronary artery calcium volume scores on electron beam tomography in 12,936 asymptomatic adults. Am J Cardiol. 2004;93:1146–9.

    Article  PubMed  CAS  Google Scholar 

  28. Detrano R, Guerci AD, Carr JJ, Bild DE, Burke G, Folsom AR, et al. Coronary calcium as a predictor of coronary events in 4 racial or ethnic groups. N Engl J Med. 2008;358:1336–45.

    Google Scholar 

  29. Greenland P, LaBree L, Azen SP, Doherty TM, Detrano RC. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA. 2004;291:210–5.

    Article  PubMed  CAS  Google Scholar 

  30. Taylor AJ, Bindeman J, Feuerstein I, Cao F, Brazaitis M, O’Malley PG. Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors: mean 3-year outcomes in the Prospective Army Coronary Calcium (PACC) project. J Am Coll Cardiol. 2005;46:807–14.

    Article  PubMed  CAS  Google Scholar 

  31. Taylor AJ, Fiorilli PN, Wu H, Bauer K, Bindeman J, Byrd C, et al. Relation between the Framingham Risk Score, coronary calcium, and incident coronary heart disease among low-risk men. Am J Cardiol. 2010;106:47–50.

    Article  PubMed  CAS  Google Scholar 

  32. Lakoski SG, Greenland P, Wong ND, Schreiner PJ, Herrington DM, Kronmal RA, et al. Coronary artery calcium scores and risk for cardiovascular events in women classified as “low risk” based on Framingham risk score: the multi-ethnic study of atherosclerosis (MESA). Arch Intern Med. 2007;167:2437–42.

    Article  PubMed  Google Scholar 

  33. Elias-Smale SE, Proenca RV, Koller MT, Kavousi M, Van Rooij FJ, Hunink MG, et al. Coronary calcium score improves classification of coronary heart disease risk in the elderly: the Rotterdam study. J Am Coll Cardiol. 2010;56:1407–14.

    Google Scholar 

  34. Erbel R, Mohlenkamp S, Moebus S, Schmermund A, Lehmann N, Stang A, et al. Coronary risk stratification, discrimination, and reclassification improvement based on quantification of subclinical coronary atherosclerosis: the Heinz Nixdorf Recall study. J Am Coll Cardiol. 2010;56:1397–406.

    Article  PubMed  Google Scholar 

  35. Polonsky TS, McClelland RL, Jorgensen NW, Bild DE, Burke GL, Guerci AD, et al. Coronary artery calcium score and risk classification for coronary heart disease prediction. JAMA. 2010;303:1610–6.

    Article  PubMed  CAS  Google Scholar 

  36. Blaha M, Budoff MJ, Shaw LJ, Khosa F, Rumberger JA, Berman D, et al. Absence of coronary artery calcification and all-cause mortality. JACC Cardiovasc Imaging. 2009;2:692–700.

    Article  PubMed  Google Scholar 

  37. Budoff MJ, McClelland RL, Nasir K, Greenland P, Kronmal RA, Kondos GT, et al. Cardiovascular events with absent or minimal coronary calcification: the Multi-Ethnic study of Atherosclerosis (MESA). Am Heart J. 2009;158:554–61.

    Article  PubMed  Google Scholar 

  38. Sarwar A, Shaw LJ, Shapiro MD, Blankstein R, Hoffmann U, Cury RC, et al. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging. 2009;2:675–88.

    Article  PubMed  Google Scholar 

  39. Rozanski A, Gransar H, Shaw LJ, Kim J, Miranda-Peats L, Wong ND, et al. Impact of coronary artery calcium scanning on coronary risk factors and downstream testing the EISNER (Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research) prospective randomized trial. J Am Coll Cardiol. 2011;57:1622–32.

    Article  PubMed  CAS  Google Scholar 

  40. van Kempen BJ, Spronk S, Koller MT, Elias-Smale SE, Fleischmann KE, Ikram MA, et al. Comparative effectiveness and cost-effectiveness of computed tomography screening for coronary artery calcium in asymptomatic individuals. J Am Coll Cardiol. 2011;58:1690–701.

    Article  PubMed  Google Scholar 

  41. Anand DV, Lim E, Hopkins D, Corder R, Shaw LJ, Sharp P, 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;27:713–21.

    Article  PubMed  Google Scholar 

  42. Becker A, Leber AW, Becker C, von Ziegler F, Tittus J, Schroeder I, et al. Predictive value of coronary calcifications for future cardiac events in asymptomatic patients with diabetes mellitus: a prospective study in 716 patients over 8 years. BMC Cardiovasc Disord. 2008;8:27.

    Article  PubMed  Google Scholar 

  43. Elkeles RS, Godsland IF, Feher MD, Rubens MB, Roughton M, Nugara F, et al. Coronary calcium measurement improves prediction of cardiovascular events in asymptomatic patients with type 2 diabetes: the PREDICT study. Eur Heart J. 2008;29:2244–51.

    Article  PubMed  CAS  Google Scholar 

  44. Anand DV, Lim E, Darko D, Bassett P, Hopkins D, Lipkin D, et al. Determinants of progression of coronary artery calcification in type 2 diabetes role of glycemic control and inflammatory/vascular calcification markers. J Am Coll Cardiol. 2007;50:2218–25.

    Article  PubMed  CAS  Google Scholar 

  45. • Malik S, Budoff MJ, Katz R, Blumenthal RS, Bertoni AG, Nasir K, et al. Impact of subclinical atherosclerosis on cardiovascular disease events in individuals with metabolic syndrome and diabetes: the multi-ethnic study of atherosclerosis. Diabetes Care. 2011;34:2285–90. This MESA substudy shows that more than a third of asymptomatic diabetics have a CAC score of 0. CAC scoring is additive to risk factor scoring systems unlike carotid intimal-medial thickness.

    Article  PubMed  Google Scholar 

  46. Wong ND, Sciammarella MG, Polk D, Gallagher A, Miranda-Peats L, Whitcomb B, et al. The metabolic syndrome, diabetes, and subclinical atherosclerosis assessed by coronary calcium. J Am Coll Cardiol. 2003;41:1547–53.

    Article  PubMed  CAS  Google Scholar 

  47. Raggi P, Cooil B, Ratti C, Callister TQ, Budoff M. Progression of coronary artery calcium and occurrence of myocardial infarction in patients with and without diabetes mellitus. Hypertension. 2005;46:238–43.

    Article  PubMed  CAS  Google Scholar 

  48. Raggi P, Shaw LJ, Berman DS, Callister TQ. Prognostic value of coronary artery calcium screening in subjects with and without diabetes. J Am Coll Cardiol. 2004;43:1663–9.

    Article  PubMed  CAS  Google Scholar 

  49. Bulugahapitiya U, Siyambalapitiya S, Sithole J, Idris I. Is diabetes a coronary risk equivalent? Systematic review and meta-analysis. Diabet Med. 2009;26:142–8.

    Article  PubMed  CAS  Google Scholar 

  50. 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;339:229–34.

    Article  PubMed  CAS  Google Scholar 

  51. Silverman MG, Blaha MJ, Budoff MJ, Rivera JJ, Raggi P, Shaw LJ, et al. Potential implications of coronary artery calcium testing for guiding aspirin use among asymptomatic individuals with diabetes. Diabetes Care. 2012;35:624–6.

    Article  PubMed  CAS  Google Scholar 

  52. O’Malley PG, Feuerstein IM, Taylor AJ. Impact of electron beam tomography, with or without case management, on motivation, behavioral change, and cardiovascular risk profile: a randomized controlled trial. JAMA. 2003;289:2215–23.

    Article  PubMed  Google Scholar 

  53. Budoff MJ, Hokanson JE, Nasir K, Shaw LJ, Kinney GL, Chow D, et al. Progression of coronary artery calcium predicts all-cause mortality. JACC Cardiovasc Imaging. 2010;3:1229–36.

    Article  PubMed  Google Scholar 

  54. Blaha MJ, DeFilippis AP, Rivera JJ, Budoff MJ, Blankstein R, Agatston A, et al. The relationship between insulin resistance and incidence and progression of coronary artery calcification: the Multi-Ethnic Study of Atherosclerosis (MESA). Diabetes Care. 2011;34:749–51.

    Article  PubMed  Google Scholar 

  55. Budoff MJ, Yu D, Nasir K, Mehrotra R, Chen L, Takasu J, et al. Diabetes and progression of coronary calcium under the influence of statin therapy. Am Heart J. 2005;149:695–700.

    Article  PubMed  CAS  Google Scholar 

  56. • Wong ND, Nelson JC, Granston T, Bertoni AG, Blumenthal RS, Carr JJ, et al. Metabolic syndrome, diabetes, and incidence and progression of coronary calcium: the Multiethnic study of Atherosclerosis study. JACC Cardiovasc Imaging. 2012;5:358–66. This MESA substudy showed that patients with diabetes mellitus had greater progression of coronary calcium than patients with metabolic syndrome. Progression of coronary artery calcium was shown to be independantly associated with cardiovascular mortality.

    Article  PubMed  Google Scholar 

  57. Kronmal RA, McClelland RL, Detrano R, Shea S, Lima JA, Cushman M, et al. Risk factors for the progression of coronary artery calcification in asymptomatic subjects: results from the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2007;115:2722–30.

    Article  PubMed  Google Scholar 

  58. Lee KK, Fortmann SP, Fair JM, Iribarren C, Rubin GD, Varady A, et al. Insulin resistance independently predicts the progression of coronary artery calcification. Am Heart J. 2009;157:939–45.

    Article  PubMed  CAS  Google Scholar 

  59. Callister TQ, Raggi P, Cooil B, Lippolis NJ, Russo DJ. Effect of HMG-CoA reductase inhibitors on coronary artery disease as assessed by electron-beam computed tomography. N Engl J Med. 1998;339:1972–8.

    Article  PubMed  CAS  Google Scholar 

  60. Byon CH, Sun Y, Chen J, Yuan K, Mao X, Heath JM, et al. Runx2-upregulated receptor activator of nuclear factor kappaB ligand in calcifying smooth muscle cells promotes migration and osteoclastic differentiation of macrophages. Arterioscler Thromb Vasc Biol. 2011;31:1387–96.

    Article  PubMed  CAS  Google Scholar 

  61. Terry JG, Carr JJ, Kouba EO, Davis DH, Menon L, Bender K, et al. Effect of simvastatin (80 mg) on coronary and abdominal aortic arterial calcium (from the coronary artery calcification treatment with zocor [CATZ] study). Am J Cardiol. 2007;99:1714–7.

    Article  PubMed  CAS  Google Scholar 

  62. Moralidis E, Didangelos T, Arsos G, Athyros V, Mikhailidis DP. Myocardial perfusion scintigraphy in asymptomatic diabetic patients: a critical review. Diabetes Metab Res Rev. 2010;26:336–47.

    Article  PubMed  CAS  Google Scholar 

  63. Wackers FJ, Young LH, Inzucchi SE, Chyun DA, Davey JA, Barrett EJ, et al. Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study. Diabetes Care. 2004;27:1954–61.

    Article  PubMed  Google Scholar 

  64. Consensus development conference on the diagnosis of coronary heart disease in people with diabetes: 10-11 February 1998, Miami, Florida. American Diabetes Association. Diabetes Care. 1998;21:1551–9.

  65. Scognamiglio R, Negut C, Ramondo A, Tiengo A, Avogaro A. Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus. J Am Coll Cardiol. 2006;47:65–71.

    Article  PubMed  Google Scholar 

  66. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(Suppl 1):S11–63.

    Google Scholar 

  67. Bax JJ, Young LH, Frye RL, Bonow RO, Steinberg HO, Barrett EJ. Screening for coronary artery disease in patients with diabetes. Diabetes Care. 2007;30:2729–36.

    Article  PubMed  Google Scholar 

  68. Selvin E, Marinopoulos S, Berkenblit G, Rami T, Brancati FL, Powe NR, et al. Meta-analysis: glycosylated hemoglobin and cardiovascular disease in diabetes mellitus. Ann Intern Med. 2004;141:421–31.

    Article  PubMed  CAS  Google Scholar 

  69. Gerstein HC, Miller ME, Byington RP, Goff DC, Bigger JT, Buse JB, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358:2545–59.

    Article  PubMed  CAS  Google Scholar 

  70. Patel A, MacMahon S, Chalmers J, Neal B, Billot L, Woodward M, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358:2560–72.

    Article  PubMed  CAS  Google Scholar 

  71. Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven PD, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009;360:129–39.

    Article  PubMed  CAS  Google Scholar 

  72. Pignone M, Alberts MJ, Colwell JA, Cushman M, Inzucchi SE, Mukherjee D, et al. Aspirin for primary prevention of cardiovascular events in people with diabetes: a position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. Circulation. 2010;121:2694–701.

    Article  PubMed  Google Scholar 

  73. Qu W, Le TT, Azen SP, Xiang M, Wong ND, Doherty TM, et al. Value of coronary artery calcium scanning by computed tomography for predicting coronary heart disease in diabetic subjects. Diabetes Care. 2003;26:905–10.

    Article  PubMed  Google Scholar 

  74. Callister T, Janowitz W, Raggi P. Sensitivity of 2 electron beam tomography protocols for the detection and quantification of coronary artery calcium. Am J Roentgenol. 2000;175:1743–6.

    Article  CAS  Google Scholar 

Download references

Conflict of Interest

Haider Javed Warraich declares that he has no conflict of interest.

Khurram Nasir declares that he has no conflict of interest.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Khurram Nasir.

Additional information

This article is part of the Topical Collection on Diabetes and Cardiovascular Disease

Rights and permissions

Reprints and permissions

About this article

Cite this article

Warraich, H.J., Nasir, K. Subclinical Cardiovascular Disease Assessment in Persons with Diabetes. Curr Cardiol Rep 15, 358 (2013). https://doi.org/10.1007/s11886-013-0358-2

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11886-013-0358-2

Keywords

Navigation