Screening for Coronary Artery Disease in Patients With Diabetes

Abstract

Coronary artery disease (CAD) accounts for a large fraction of the morbidity, mortality, and cost of diabetes. Recognizing this, nearly 10 years ago the American Diabetes Association published a consensus recommendation that clinicians consider a risk factor–guided screening approach to early diagnosis of CAD in both symptomatic and asymptomatic patients. Subsequent clinical trial results have not supported those recommendations. Since the prior consensus statement, newer imaging methods, such as coronary artery calcium scoring and noninvasive angiography with computed tomography (CT) techniques, have come into use. These technologies, which allow quantitation of atherosclerotic burden and can predict risk of cardiac events, might provide an approach to more widespread coronary atherosclerosis screening. However, over this same time interval, there has been recognition of diabetes as a cardiovascular disease (CVD) equivalent, clear demonstration that medical interventions should provide primary and secondary CVD risk reduction in diabetic populations, and suggestive evidence that percutaneous coronary revascularization may not provide additive survival benefit to intensive medical management in patients with stable CAD. This additional evidence raises the question of whether documenting asymptomatic atherosclerosis or ischemia in people with diabetes is warranted. More data addressing this issue will be forthcoming from the BARI 2-D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. Until then, for patients with type 2 diabetes who are asymptomatic for CAD, we recommend that testing for atherosclerosis or ischemia, perhaps with cardiac CT as the initial test, be reserved for those in whom medical treatment goals cannot be met and for selected individuals in whom there is strong clinical suspicion of very-high-risk CAD. Better approaches to identify such individuals based on readily obtained clinical variables are sorely needed.

Managing Preexisting Diabetes for Pregnancy

“…A 1999 ADA consensus panel report on CHD and diabetes proposed that asymptomatic patients at age 35 years or more with two or more standard risk factors or the desire for vigorous exercise should be considered for coronary screening tests (128). However, in view of evidence that the burden of conventional cardiac risk factors is not predictive of presence of ischemia on perfusion imaging, at least in older patients, and that medical management (indicated anyway in people with diabetes at moderate or high CVD risk) may lead to similar outcomes compared with surgical interventions, a 2007 ADA consensus panel recommended against routine CHD screening in people with diabetes (138). The concept of screening asymptomatic diabetic women of reproductive age remains controversial and is inadequately studied (1).…”

“…Subtle symptoms, if present, may include atypical chest pain (or neck, jaw, or shoulder pain), fatigue, dyspnea, and nausea, all of which may be difficult to distinguish from common pregnancy-related symptoms (including gastroesophageal reflux). Abnormal Qwaves, deep T-wave inversions, leftbundle branch block, or nonspecific ST-T wave changes on resting ECG usually trigger evaluation for inducible ischemia (138). Should suspicion arise of CHD on historical or clinical grounds in pregnant women with diabetes, cardiology consultation and consideration of modalities to diagnose ischemia that avoid radiation exposure are recommended (140).…”

Seguimiento a Cinco Años en Pacientes Diabéticos Sin Síntomas Cardíacos Estudiados Con Perfusión Miocárdica

“…La tomografía de fotón único (SPECT) de perfusión miocárdica efectuada con estrés tiene un alto valor diagnósti-co y de estratificación de riesgo en pacientes con DM. 3,4 Existe controversia sobre la necesidad de realizar tamizaje de rutina mediante técnicas con isquemia inducida a pacientes asintomáticos cardíacos con DM .3,5,6 Se debe considerar que el tipo de prueba de provocación utilizada tiene valor pronóstico en sí misma, debido a que pacientes con DM referidos a estrés farmacológico tienen mayor gravedad y hasta 7 veces mayor mortalidad comparados con los que pueden realizar ejercicio .7,8 The clinical value of myocardial perfusion studies in cardiac asymptomatic patients with Diabetes Mellitus (DM) is controversial.…”

Angiographic Profile and Treadmill Test Relationship of Women with Chest Pain Suggestive of Coronary Artery Disease

“…Similarly, minor CAD patients have 24.2% and 37.5% of positive and negative TMT respectively. In the absence of symptomatic CAD, clinical characteristics that assist to classify patients with an elevated risk for myocardial infarction or cardiac death include evidence of other atherosclerosis, abnormal resting ECGs, autonomic neuropathy, retinopathy, chronic kidney disease, age, sex, hyperglycemia and novel cardiac risk factors [16].…”