Use of imaging and clinical data to screen for cardiovascular disease in asymptomatic diabetics

Abstract

BackgroundThere is increasing evidence to suggest that not all individuals with type 2 diabetes mellitus (T2DM) have equal risk for developing cardiovascular disease. We sought to compare the yield of testing for pre-clinical atherosclerosis with various approaches.Methods98 asymptomatic individuals with T2DM without known coronary artery disease (CAD) were enrolled in a prospective study and underwent carotid ultrasound, exercise treadmill testing (ETT), coronary artery calcium (CAC) scoring, and coronary computed tomography angiography (CTA).ResultsOf 98 subjects (average age 55 ± 6, 64 % female), 43 (44 %) had coronary plaque detectable on CTA, and 38 (39 %) had CAC score >0. By CTA, 16 (16 %) had coronary stenosis ≥50 %, including three subjects with CAC = 0. Subjects with coronary plaque had greater prevalence of carotid plaque (58 % vs. 38 %, p = 0.01) and greater carotid intima media thickness (0.80 ± 0.20 mm vs. 0.70 ± 0.11 mm, p = 0.02). Notably, 18 of 55 subjects (33 %) with normal CTA had carotid plaque. Eight subjects had a positive ETT, of whom five had ≥ 50 % coronary stenosis, two had <50 % stenosis, and one had no CAD. Among these tests, CAC scoring had the highest sensitivity and specificity for prediction of CAD.ConclusionAmong asymptomatic subjects with T2DM, a majority (56 %) had no CAD by CTA. When compared to CTA, CAC was the most accurate screening modality for detection of CAD, while ETT and carotid ultrasound were less sensitive and specific. However, 33 % of subjects with normal coronary CTA had carotid plaque, suggesting that screening for carotid plaque might better characterize stroke risk in such patients.

Vascular Events and Carotid Atherosclerosis: A 5-Year Prospective Cohort Study in Patients with Type 2 Diabetes and a Contemporary Cardiovascular Prevention Treatment

“…The potential association with diabetes (41% of the population) with the presence of carotid atherosclerosis was not investigated. Finally, two small studies that included only patients with diabetes and a low to intermediate risk of CV events found that carotid plaque was less accurate than the CAC score to predict coronary disease assessed by coronary computed tomography angiography [31] and CV events [32]. Taken together, the exclusive inclusion of patients with diabetes and a high estimated CV risk receiving contemporary preventive treatments herein could explain the absence of association between carotid atherosclerosis and CV events observed in other studies.…”

Evaluation of the impact of glycemic status on the progression of coronary artery calcification in asymptomatic individuals

“…Although multiple imaging techniques are available to detect the presence of pre-clinical disease, the efficacy of these modalities in the risk stratification of asymptomatic diabetes patients remains uncertain. Recently, Rassi et al [ 36 ] reported that CAC was the most accurate screening modality for detection of CAD, but that screening for carotid plaque using normal coronary CT angiography may better characterize stroke risk in asymptomatic diabetics. However, this study was performed in only 98 participants.…”

Obesity, metabolic syndrome and cardiovascular prognosis: from the Partners coronary computed tomography angiography registry

“…For example, although major guidelines define diabetes mellitus as high-risk for CAD events, one study screened 98 asymptomatic patients with diabetes using CAC, CTA, and carotid ultrasound and identified 55 (56%) who had no detectable CAD and could potentially be re-classified from high to low CV risk. Sixteen subjects (including three with CAC = 0) were found to have obstructive CAD by CTA, but no clinical outcomes were reported for this cross-sectional study [46]. Similarly, Ryu et al screened 755 patients with MetS by CTA and identified an increasing extent and burden of CAD according to the number of MetS risk factors, among which abdominal obesity and hypertension had the strongest effect [47].…”