Identification of coronary heart disease in asymptomatic individuals with diabetes mellitus: to screen or not to screen
Coronary heart disease (CHD) is highly prevalent in patients with diabetes mellitus (DM), and remains the single most common cause of death among this population. Regrettably, a significant percentage of diabetics fail to perceive the classic symptoms associated with myocardial ischemia. Among asymptomatic diabetics, the prevalence of abnormal cardiac testing appears to be high, raging between 10% and 62%, and mortality is significantly higher in those with abnormal scans. Hence, the potential use of screening for CHD detection among asymptomatic DM individuals is appealing and has been recommended in certain circumstances. However, it was not until recently, that this question was addressed in clinical trials. Two studies randomized a total of 2,023 asymptomatic diabetics to screening or not using cardiac imaging with a mean follow up of 4.4 ± 1.4 years. In combination, both trials showed lower than expected annual event rates, and failed to reduce major cardiovascular events in the screened group compared to the standard of care alone. The results of these trials do not currently support the use of screening tools for CHD detection in asymptomatic DM individuals. However, these studies have important limitations, and potential explanations for their negative results that are discussed in this manuscript.
- coronary heart disease
Geiss LS, Wang J, Cheng YJ, Thompson TJ, Barker L, Li Y, et al. Prevalence and incidence trends for diagnosed diabetes among adults aged 20 to 79 years, united states, 1980-2012. JAMA. 2014; 312: 1218–26.
CDC . National diabetes statistics report. Atlanta, GA, U.S: Department of Health and Human Services; 2014.
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. New England J Med. 1998; 339: 229-34.
Zaccardi F, Khan H, Laukkanen JA. Diabetes mellitus and risk of sudden cardiac death: A systematic review and meta-analysis. Internat J Cardiol. 2014; 177: 535-37
Hu FB, Stampfer MJ, Solomon CG, Liu S, Willett WC, Speizer FE, et al. The impact of diabetes mellitus on mortality from all causes and coronary heart disease in women: 20 years of follow-up. Arch Int Med. 2001; 161: 1717–23.
Cabin HS, Roberts WC. Quantitative comparison of extent of coronary narrowing and size of healed myocardial infarct in 33 necropsy patients with clinically recognized and in 28 with clinically unrecognized ("silent") previous acute myocardial infarction. Am J Cardiol. 1982;50:677–681.
Torremocha F, Hadjadj S, Carrie F, Rosenberg T, Herpin D, Marechaud R. Prediction of major coronary events by coronary risk profile and silent myocardial ischaemia: Prospective follow-up study of primary prevention in 72 diabetic patients. Diabetes Metab. 2001; 27: 49–57.
Le Feuvre CL, Barthelemy O, Dubois-Laforgue D, Maunoury C, Mogenet A, Baubion N, et al. Stress myocardial scintigraphy and dobutamine echocardiography in the detection of coronary disease in asymptomatic patients with type 2 diabetes. Diabetes Metab. 2005; 31: 135–42.
Sejil S, Janand-Delenne B, Avierinos JF, Habib G, Labastie N, Raccah D, et al. Six-year follow-up of a cohort of 203 patients with diabetes after screening for silent myocardial ischaemia. Diabetic medicine : J British Diabetic Assoc. 2006; 23: 1186–91.
Scholte AJ, Schuijf JD, Kharagjitsingh AV, Dibbets-Schneider P, Stokkel MP, et al. van der Wall EE Prevalence and predictors of an abnormal stress myocardial perfusion study in asymptomatic patients with type 2 diabetes mellitus. Eur J Nuclear Med Mol Imag. 2009; 36: 567–75.
Choi EK, Chun EJ, Choi SI, Chang SA, Choi SH, Lim S, et al. Assessment of subclinical coronary atherosclerosis in asymptomatic patients with type 2 diabetes mellitus with single photon emission computed tomography and coronary computed tomography angiography. Am J Cardiol. 2009; 104: 890–6.
Jacqueminet S, Barthelemy O, Rouzet F, Isnard R, Halbron M, Bouzamondo A, et al. A randomized study comparing isotope and echocardiography stress testing in the screening of silent myocardial ischaemia in type 2 diabetic patients. Diabetes Metab. 2010;36: 463–9.
Giovacchini G, Cappagli M, Carro S, Borrini S, Montepagani A, Leoncini R, et al. Microalbuminuria predicts silent myocardial ischaemia in type 2 diabetes patients. Eur J Nuclear Med Mol Imag. 2013;40: 548–57.
De Lorenzo A, Lima RS, Siqueira-Filho AG, Pantoja MR. Prevalence and prognostic value of perfusion defects detected by stress technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography in asymptomatic patients with diabetes mellitus and no known coronary artery disease. Am J Cardiol. 2002; 90: 827–32.
Yamasaki Y, Nakajima K, Kusuoka H, Izumi T, Kashiwagi A, Kawamori R, et al. Prognostic value of gated myocardial perfusion imaging for asymptomatic patients with type 2 diabetes: The j-access 2 investigation. Diabetes Care. 2010; 33: 2320–6.
Rajagopalan N, Miller TD, Hodge DO, Frye RL, Gibbons RJ. Identifying high-risk asymptomatic diabetic patients who are candidates for screening stress single-photon emission computed tomography imaging. J Am Coll Cardiol. 2005; 45: 43–9.
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.
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.
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.
Young LH, Wackers FJ, 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. JAMA. 2009; 301: 1547–55.
Muhlestein JB, Lappe DL, Lima JA, 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. JAMA. 2014; 312: 2234-43.
Wannamethee SG, Shaper AG, Whincup PH, Lennon L, Sattar N. Impact of diabetes on cardiovascular disease risk and all-cause mortality in older men: Influence of age at onset, diabetes duration, and established and novel risk factors. Arch Int Med. 2011; 171: 404–10.
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. New England J Med. 2007; 356: 1503–16.
Frye RL, August P, Brooks MM, Hardison RM, Kelsey SF, MacGregor JM, et al. A randomized trial of therapies for type 2 diabetes and coronary artery disease. New England J Med. 2009; 360: 2503–15.
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