Cardiovascular Risk Prediction Is Improved by Adding Asymptomatic Coronary Status to Routine Risk Assessment in Type 2 Diabetic Patients

Abstract

OBJECTIVETo evaluate if silent myocardial ischemia (SMI) and silent coronary artery disease (CAD) provide significant additional value to routine cardiovascular risk assessment in type 2 diabetic patients.RESEARCH DESIGN AND METHODSWe followed up to a first cardiovascular event 688 subjects (322 men, aged 59 ± 8 years) out of 731 consecutive asymptomatic type 2 diabetic patients with ≥1 additional risk factor who had been prospectively screened between 1992 and 2006 for SMI by stress myocardial scintigraphy and for silent CAD by coronary angiography.RESULTSSMI was found in 207 (30.1%) patients and CAD in 76 of those with SMI. Of the patients, 98 had a first cardiovascular event during a 5.4 ± 3.5 (range: 0.1–19.2) year follow-up period. Cox regression analysis considering parameters predicting events but not SMI and CAD (“routine assessment”) showed in univariate analyses that macroproteinuria (hazard ratio [HR] 3.33 [95% CI 1.74–6.35]; P < 0.001), current multifactorial care (0.27 [0.15–0.47]; P < 0.001), and peripheral/carotid occlusive arterial disease (PCOAD; 4.33 [2.15–8.71]; P < 0.001) independently predicted cardiovascular events. When added into the model, SMI (HR 1.76 [1.00–3.12]; P = 0.05) and CAD (2.28 [1.24–4.57]; P < 0.01) were also independently associated with events. SMI added to the prediction of an event in the following 5 years above and beyond routine assessment risk prediction (c statistic with or without SMI 0.788 [0.720–0.855] and 0.705 [0.616–0.794], respectively).CONCLUSIONSAlthough screening for SMI and silent CAD should not be systematic, these complications are predictive of cardiovascular events in type 2 diabetic patients in addition to routine risk predictors, especially represented by PCOAD, macroproteinuria, and nonintensive management.

ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD – Summary

“…SMI is a major cardiac risk factor when associated with coronary stenoses at angiography and the predictive value of SMI and silent coronary stenoses adds to routine risk estimate. 53 Further evidence is needed to support screening for SMI, which may be carried out in those at very high risk (with evidence of PAD, high CAC score or proteinuria), and in subjects who wish to start exercise programmes. 54 In patients with SMI, coronary revascularization may be proposed on an individual basis.…”

Coronary artery disease is detectable by multi-slice computed tomography in most asymptomatic type 2 diabetic patients at high cardiovascular risk

“…A very recent multicentre study 28 suggests that cardiovascular risk prediction is improved by adding asymptomatic CAD, diagnosed through coronary angiography, to routine risk assessment in type 2 diabetic patients with ≥1 additional risk factor. In particular, during a 5.4±3.5 years follow-up period, asymptomatic CAD was independently associated with a first cardiovascular event, with a risk increase greater than two-fold.…”

Wytyczne ESC dotyczące cukrzycy, stanu przedcukrzycowego i chorób układu sercowo- -naczyniowego opracowane we współpracy z EASD

“…Występuje ono u 20-35% chorych na cukrzycę z dodatkowymi czynnikami ryzyka, a u 35-70% pacjentów ze SMI stwierdza się istotne zwęże-nia tętnic wieńcowych w angiografii, podczas gdy u innych SMI może być następstwem zaburzeń czynności śródbłonka tętnic wieńcowych lub mikrokrążenia wieńcowego. Nieme niedokrwienie mięśnia sercowego jest głównym czynnikiem ryzyka sercowego, zwłaszcza w połączeniu ze zwężeniem tętnic wieńcowych w angiografii; wartość prognostyczna SMI i bezobjawowych zwężeń tętnic wieńcowych stanowi uzupełnienie rutynowej metody szacowania ryzyka [121]. Jednak istnieją rozbieżne opinie na temat rutynowych badań przesiewowych w kierunku CAD u bezobjawowych pacjentów.…”