Effect of Screening for Coronary Artery Disease Using CT Angiography on Mortality and Cardiac Events in High-Risk Patients With Diabetes

Muhlestein, Joseph B.; Lappé, Donald; Lima, João A.C.; Rosen, Boaz D.; May, Heidi T.; Knight, Stacey; Bluemke, David A.; Towner, Steven; Le, Viet T; Bair, Tami L; Vavere, Andrea L.; Anderson, Jeffrey L.

doi:10.1001/jama.2014.15825

Cited by 334 publications

(226 citation statements)

References 18 publications

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“…CCTA may be a good modality to triage diabetes individuals who are at high risk of future CVD events due to the direct visualization of subclinical atherosclerosis including non-calcified plaque [14,16]. A recent prospective randomized trial in 900 asymptomatic diabetes individuals demonstrated that CCTA reduced risk of major adverse cardiovascular events by 20% compared to standard diabetes care; however, this failed to achieve statistical significance (HR 0.80, 95% CI 0.49e1.32, p ¼ 0.38) [46].…”

Section: Discussionmentioning

confidence: 99%

Plaque progression assessed by a novel semi-automated quantitative plaque software on coronary computed tomography angiography between diabetes and non-diabetes patients: A propensity-score matching study

et al. 2016

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Plaque progression assessed by a novel semi-automated quantitative plaque software on coronary computed tomography angiography between diabetes and non-diabetes patients: A propensity-score matching study Methods: We identified 142 study subjects undergoing serial coronary computed tomography angiography. The resulting propensity score was applied 1:1 to match diabetic patients to non-diabetic patients for clinical risk factors, prior coronary stenting, coronary artery calcium (CAC) score and the serial scan interval, resulting in the 71 diabetes and 71 non-diabetes patients. Coronary plaque (total, calcified, noncalcified including fibrous, fibrous-fatty and low attenuation plaque [LAP]) volume normalized by total coronary artery length was measured using semi-automated plaque software and its change overtime between diabetic and non-diabetic patients was evaluated.Results: The matching was successful without significant differences between the two groups in all matched variables. The baseline volumes in each plaque also did not differ. During a mean scan interval of 3.4 ± 1.8 years, diabetic patients showed a 2-fold greater progression in normalized total plaque volume (TPV) than non-diabetes patients (52.8 mm 3 vs. 118.3 mm 3 , p ¼ 0.005). Multivariable linear regression model revealed that diabetes was associated with normalized TPV progression (b 72.3, 95%CI 24.3e120.3). A similar trend was observed for the non-calcified components, but not calcified plaque (b 3.8, 95%CI À27.0e34.7). Higher baseline CAC score was found to be associated with total, non-calcified and calcified plaque progression. However, baseline non-calcified volume but not CAC score was associated with LAP progression. Conclusions: The current study among matched patients indicates diabetes is associated with a greater plaque progression. Our results show the need for strict adherence of diabetic patients to the current preventive guidelines.

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Section: Discussionmentioning

confidence: 99%

Plaque progression assessed by a novel semi-automated quantitative plaque software on coronary computed tomography angiography between diabetes and non-diabetes patients: A propensity-score matching study

et al. 2016

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“…Overall, annual event rates in both the control and intervention groups were low (<2%), and outcomes (death, MI, or unstable angina) did not differ significantly between the CCTA and no CCTA groups after a mean of 4 years of follow-up. 74 At present, these findings do not support CCTA screening for risk assessment of individuals without chest pain.…”

Section: Disclosuresmentioning

confidence: 69%

Role of Cardiac Multidetector Computed Tomography Beyond Coronary Angiography

Sato

Aonuma

2015

Circ J

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712SATO A et al. Circulation JournalOfficial Journal of the Japanese Circulation Society http://www. j-circ.or.jp for detecting coronary artery stenosis has been compared with ICA. Several studies have demonstrated the ability of CCTA to detect anatomically significant CAD with high negative predictive value (NPV). The CORE 64 study demonstrated that the patient-based diagnostic accuracy of quantitative CCTA for detecting stenoses ≥50% according to ICA revealed an area under the curve (AUC) of 0.93, with sensitivity of 85%, specificity of 90%, positive predictive value (PPV) of 91%, and NPV of 83%. 7 The 64-slice CCTA is accurate in identifying coronary stenoses and characterizing disease severity in symptomatic patients who have coronary artery calcium scores (CACS) <600. Given its PPV of 91% and NPV of 83%, 64-slice CCTA cannot replace conventional ICA. The substudy of CORE 64 showed that the AUC for diagnostic accuracy was similar (0.93, 0.92, and 0.93, respectively) for patients with intermediate, high pretest probability for CAD, and known CAD, whereas the NPV was different (0.90, 0.83, and 0.50, respectively). For excluding obstructive CAD, CCTA was less effective in patients with calcium score ≥600 and high pretest probability for obstructive CAD. 13 In the CONFIRM study, the prevalence of observed CAD with either ≥50% diameter stenosis (CAD50) or 70% diameter stenosis (CAD70) was substantially lower than predicted by guideline probabilities in the overall population (18% vs. 51% for CAD50, 10% vs.ultidetector computed tomography (MDCT) is well established for more precise evaluation of coronary stenosis relative to electron-beam CT. 1-3 Multicenter studies have confirmed the accuracy of 64-slice MDCT for directly visualizing and detecting coronary artery stenoses in patients with suspected coronary artery disease (CAD). 4-7 Furthermore, dual-source CT (DSCT), 256-slice, and 320-detector scanner were developed to significantly improve scan times, volume coverage, and spatial resolution. 8-12 With improvement in the technical aspects of coronary computed tomography angiography (CCTA), clinical practice and research are increasingly shifting toward defining the clinical implication of plaque morphology, myocardial perfusion imaging (MPI), and patient outcomes. In this review, we discuss the role of cardiac MDCT beyond coronary angiography, including a comparison with other currently available imaging modalities used to examine atherosclerotic plaque and myocardial perfusion. Diagnosis of CAD Role of Cardiac Multidetector Computed Tomography Beyond Coronary AngiographyAkira Sato, MD; Kazutaka Aonuma, MD, PhDCardiac multidetector computed tomography (MDCT) has become a useful noninvasive modality for anatomical imaging of coronary artery disease (CAD). Currently, the main clinical advantage of coronary computed tomography angiography (CCTA) appears to be related to its high negative predictive value at low or intermediate pretest probability for CAD. With the development of technical aspects of MDCT, clinica...

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“…Similarly, the Screening For Asymptomatic Obstructive Coronary Artery Disease Among High-Risk Diabetic Patients Using CT Angiography, Following Core 64 (FACTOR 64) trial randomised patients with diabetes and no symptoms of CAD to screening coronary computed tomography angiography (CCTA) or usual care. 5 After a mean follow-up of 4.0 years there was no significant difference in event rates between the screened and unscreened groups (6.2 versus 7.6 %). Randomisation to CCTA resulted in only 36 (8 %) coronary angiographies and 26 (5.8 %) coronary revascularisations.…”

Section: Decision To Perform Revascularisationmentioning

confidence: 75%

Determining the Most Appropriate Mode of Coronary Artery Revascularisation in Patients With Diabetes

Armstrong

Waldo

2016

Interventional Cardiology Review

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CoronaryPatients with diabetes mellitus (DM) have an increased prevalence of coronary artery disease (CAD) and are more likely to require coronary revascularisation than patients without DM. 1 Similar to the general population, CAD remains the most frequent cause of death among patients with DM. 2 As the prevalence of DM continues to rise worldwide, the appropriate management and method of revascularisation for diabetic patients will become an increasingly important clinical decision point. In this review, we discuss current data regarding the indications and optimal method of coronary revascularisation among patients with DM. Decision to Perform RevascularisationAs with the general population, patients with DM and CAD may present with asymptomatic ischaemia, stable angina or acute coronary syndromes. The clinical presentation and severity of symptoms significantly influences the decision to perform coronary artery revascularisation, as well as the relative timing of such a procedure.Although patients with DM have a higher prevalence of CAD, the majority of patients are asymptomatic before presenting with a myocardial infarction or other cardiovascular event. 3 Numerous studies have therefore investigated the use of routine screening for CAD among diabetic patients that do not have overt symptoms. The Detection of Ischaemia in Asymptomatic Diabetics (DIAD) study investigated routine screening for coronary ischaemia using myocardial perfusion imaging among asymptomatic diabetic patients. 4 During a mean follow-up of 4.8 years, the overall cardiac event rate was only 2.9 % with an event rate of 2.7 % in the screened group and 3.0 % in the unscreened group. The overall rate of revascularisation was also low at 5.5 % in the screened group and 7.8 % in the unscreened group. Similarly, the Screening For Together these two large randomised trials do not support a strategy of routine testing for CAD among asymptomatic diabetic patients.Among diabetic patients with symptomatic stable CAD, the decision to pursue revascularisation with either a percutaneous or surgical approach was studied in the Bypass Angioplasty Revascularisation Investigation in Type 2 Diabetes (BARI 2D) study. 6 In that trial diabetic patients with stable CAD were randomised to either optimal medical therapy with immediate percutaneous or surgical revascularisation at the discretion of the investigator or optimal medical therapy alone.At 5 years there was no difference in overall mortality between the two groups, although the rate of subsequent revascularisation in the medical therapy group was 38 % at 5 years. These results suggest that immediate revascularisation is not necessary among patients with DM and stable CAD in the absence of severe anginal symptoms, while recognising that a significant percentage of patients will eventually require revascularisation due to worsening of their symptoms. AbstractObstructive coronary artery disease is a common cause of morbidity and mortality among patients with diabetes mellitus (DM). Previous research has d...

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Effect of Screening for Coronary Artery Disease Using CT Angiography on Mortality and Cardiac Events in High-Risk Patients With Diabetes

Abstract: clinicaltrials.gov Identifier: NCT00488033.

Cited by 334 publications

References 18 publications

Plaque progression assessed by a novel semi-automated quantitative plaque software on coronary computed tomography angiography between diabetes and non-diabetes patients: A propensity-score matching study

Plaque progression assessed by a novel semi-automated quantitative plaque software on coronary computed tomography angiography between diabetes and non-diabetes patients: A propensity-score matching study

Role of Cardiac Multidetector Computed Tomography Beyond Coronary Angiography

Determining the Most Appropriate Mode of Coronary Artery Revascularisation in Patients With Diabetes

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