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Pezel T, Hovasse T, Sanguineti F, Kinnel M, Garot P, Champagne S, Toupin S, Unterseeh T, Garot J. Long-Term Prognostic Value of Stress CMR in Patients With Heart Failure and Preserved Ejection Fraction. JACC Cardiovasc Imaging 2021; 14:2319-2333. [PMID: 34419409 DOI: 10.1016/j.jcmg.2021.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/22/2021] [Accepted: 03/04/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The objectives of this study were to investigate the long-term prognostic value of inducible myocardial ischemia assessed by vasodilator stress cardiovascular magnetic resonance (CMR) in patients with HFpEF. BACKGROUND Some studies suggest that ischemia could play a key role in HF in patients with preserved ejection fraction (HFpEF). METHODS Between 2008 and 2019, consecutive patients prospectively referred for stress CMR with HFpEF as defined by current guidelines, without known coronary artery disease (CAD), were followed for the occurrence of major adverse cardiovascular events (MACE), as defined by cardiovascular mortality or nonfatal myocardial infarction (MI). Secondary composite outcomes included cardiovascular mortality or hospitalization for acute HF. Cox regression analysis was performed to determine the prognostic value of inducible ischemia or late gadolinium enhancement (LGE) by CMR. RESULTS Among the 1,203 patients with HFpEF (73 ± 13 years of age; 29% males) who underwent stress CMR and completed follow-up (6.9 years interquartile range [IQR]: 6.7 to 7.7 years]), 108 experienced a MACE (9%). Kaplan-Meier analysis showed inducible ischemia and LGE were significantly associated with MACE (HR: 6.63; 95% confidence interval [CI]: 4.54 to 9.69; and HR: 2.56; 95% CI: 1.60 to 4.09, respectively; both p < 0.001) and secondary outcomes (HR: 8.40; 95% CI: 6.31 to 11.20; p < 0.001; and HR: 1.87; 95% CI: 1.27 to 2.76, respectively; p = 0.002). In multivariate analysis, inducible ischemia and LGE were independent predictors of MACE (HR: 6.10; 95% CI: 4.14 to 9.00; p < 0.001 and HR: 1.62; 95% CI: 1.06 to 2.49; p = 0.039; respectively). CONCLUSIONS Stress CMR-inducible myocardial ischemia and LGE have accurate discriminative long-term prognostic value in HFpEF patients without known CAD to predict the occurrence of MACE.
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Affiliation(s)
- Théo Pezel
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France; Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Thomas Hovasse
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France
| | - Francesca Sanguineti
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France
| | - Marine Kinnel
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France
| | - Stéphane Champagne
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France
| | | | - Thierry Unterseeh
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France
| | - Jérôme Garot
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France.
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Stacey RB, Vera T, Morgan TM, Jordan JH, Whitlock MC, Hall ME, Vasu S, Hamilton C, Kitzman DW, Hundley WG. Asymptomatic myocardial ischemia forecasts adverse events in cardiovascular magnetic resonance dobutamine stress testing of high-risk middle-aged and elderly individuals. J Cardiovasc Magn Reson 2018; 20:75. [PMID: 30463565 PMCID: PMC6249873 DOI: 10.1186/s12968-018-0492-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 10/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current guidelines for assessing the risk of experiencing a hospitalized cardiovascular (CV) event discourage stress testing of asymptomatic individuals; however, these recommendations are based on evidence gathered primarily from those aged < 60 years, and do not address the possibility of unrecognized "silent myocardial ischemia" in middle aged and older adults. METHODS We performed dobutamine cardiovascular magnetic resonance (CMR) stress testing in 327 consecutively recruited participants aged > 55 years without CV-related symptoms nor known coronary artery disease, but otherwise at increased risk for a future CV event due to pre-existing hypertension or diabetes mellitus for at least 5 years. After adjusting for the demographics and CV risk factors, log-rank test and Cox proportional hazards models determined the additional predictive value of the stress test results for forecasting hospitalized CV events/survival. Either stress-induced LV wall motion abnormalities or perfusion defects were used to indicate myocardial ischemia. RESULTS Participants averaged 68 ± 8 years in age; 39% men, 75% Caucasian. There were 38 hospitalized CV events or deaths which occurred during a mean follow-up of 58 months. Using Kaplan-Meier analyses, myocardial ischemia identified future CV events/survival (p < 0.001), but this finding was more evident in men (p < 0.001) versus women (p = 0.27). The crude hazard ratio (HR) of myocardial ischemia for CV events/survival was 3.13 (95% CI: 1.64-5.93; p < 0.001). After accounting for baseline demographics, CV risk factors, and left ventricular ejection fraction/mass, myocardial ischemia continued to be associated with CV events/survival [HR: 4.07 (95% CI: 1.95-8.73) p < 0.001]. CONCLUSIONS Among asymptomatic middle-aged individuals with risk factors for a sentinel CV event, the presence of myocardial ischemia during dobutamine CMR testing forecasted a future hospitalized CV event or death. Further studies are needed in middle aged and older individuals to more accurately characterize the prevalence, significance, and management of asymptomatic myocardial ischemia. TRIAL REGISTRATION ( ClinicalTrials.gov identifier): NCT00542503 and was retrospectively registered on October 11th, 2007.
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Affiliation(s)
- R. Brandon Stacey
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - Trinity Vera
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - Timothy M. Morgan
- Department of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Jennifer H. Jordan
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - Matthew C. Whitlock
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, Palo Alto, CA USA
| | - Michael E. Hall
- Department of Medicine (Cardiovascular Medicine), University of Mississippi Medical Center, Jackson, MS USA
| | - Sujethra Vasu
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - Craig Hamilton
- Department of Radiology (Division of Radiologic Sciences), Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Dalane W. Kitzman
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - W. Gregory Hundley
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
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Prevalencia de cardiopatía isquémica asintomática en pacientes con diabetes mellitus tipo 2. REVISTA COLOMBIANA DE CARDIOLOGÍA 2018. [DOI: 10.1016/j.rccar.2017.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Bertoluci MC, Moreira RO, Faludi A, Izar MC, Schaan BD, Valerio CM, Bertolami MC, Chacra AP, Malachias MVB, Vencio S, Saraiva JFK, Betti R, Turatti L, Fonseca FAH, Bianco HT, Sulzbach M, Bertolami A, Salles JEN, Hohl A, Trujilho F, Lima EG, Miname MH, Zanella MT, Lamounier R, Sá JR, Amodeo C, Pires AC, Santos RD. Brazilian guidelines on prevention of cardiovascular disease in patients with diabetes: a position statement from the Brazilian Diabetes Society (SBD), the Brazilian Cardiology Society (SBC) and the Brazilian Endocrinology and Metabolism Society (SBEM). Diabetol Metab Syndr 2017; 9:53. [PMID: 28725272 PMCID: PMC5512820 DOI: 10.1186/s13098-017-0251-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/30/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Since the first position statement on diabetes and cardiovascular prevention published in 2014 by the Brazilian Diabetes Society, the current view on primary and secondary prevention in diabetes has evolved as a result of new approaches on cardiovascular risk stratification, new cholesterol lowering drugs, and new anti-hyperglycemic drugs. Importantly, a pattern of risk heterogeneity has emerged, showing that not all diabetic patients are at high or very high risk. In fact, most younger patients who have no overt cardiovascular risk factors may be more adequately classified as being at intermediate or even low cardiovascular risk. Thus, there is a need for cardiovascular risk stratification in patients with diabetes. The present panel reviews the best current evidence and proposes a practical risk-based approach on treatment for patients with diabetes. MAIN BODY The Brazilian Diabetes Society, the Brazilian Society of Cardiology, and the Brazilian Endocrinology and Metabolism Society gathered to form an expert panel including 28 cardiologists and endocrinologists to review the best available evidence and to draft up-to-date an evidence-based guideline with practical recommendations for risk stratification and prevention of cardiovascular disease in diabetes. The guideline includes 59 recommendations covering: (1) the impact of new anti-hyperglycemic drugs and new lipid lowering drugs on cardiovascular risk; (2) a guide to statin use, including new definitions of LDL-cholesterol and in non-HDL-cholesterol targets; (3) evaluation of silent myocardial ischemia and subclinical atherosclerosis in patients with diabetes; (4) hypertension treatment; and (5) the use of antiplatelet therapy. CONCLUSIONS Diabetes is a heterogeneous disease. Although cardiovascular risk is increased in most patients, those without risk factors or evidence of sub-clinical atherosclerosis are at a lower risk. Optimal management must rely on an approach that will cover both cardiovascular disease prevention in individuals in the highest risk as well as protection from overtreatment in those at lower risk. Thus, cardiovascular prevention strategies should be individualized according to cardiovascular risk while intensification of treatment should focus on those at higher risk.
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Affiliation(s)
- Marcello Casaccia Bertoluci
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2400, Porto Alegre, RS 90035-003 Brazil
- Serviço de Medicina Interna, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS 90035-903 Brazil
| | - Rodrigo Oliveira Moreira
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Rua Moncorvo Filho, 90, Rio de Janeiro, RJ 20211-340 Brazil
- Faculdade de Medicina de Valença (FMV), Rua Sebastião Dantas Moreira, 40, Valença, RJ 27600-000 Brazil
- Faculdade de Medicina da Universidade Presidente Antônio Carlos (FAME/UNIPAC), Av. Juiz de Fora, 1100, Juiz De Fora, MG 36048-000 Brazil
| | - André Faludi
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - Maria Cristina Izar
- Universidade Federal de São Paulo (UNIFESP), Rua Loefgren, 1350, São Paulo, SP 04040-001 Brazil
| | | | - Cynthia Melissa Valerio
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Rua Moncorvo Filho, 90, Rio de Janeiro, RJ 20211-340 Brazil
| | - Marcelo Chiara Bertolami
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - Ana Paula Chacra
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | | | - Sérgio Vencio
- Universidade Federal de Goiás (UFG), 1ª Avenida, s/n, Setor Leste Universitário, Goiânia, GO 74605-020 Brazil
| | - José Francisco Kerr Saraiva
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Av. John Boyd Dunlop, s/n, Campinas, SP 13059-900 Brazil
| | - Roberto Betti
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | - Luiz Turatti
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | | | - Henrique Tria Bianco
- Universidade Federal de São Paulo (UNIFESP), Rua Loefgren, 1350, São Paulo, SP 04040-001 Brazil
| | - Marta Sulzbach
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - Adriana Bertolami
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - João Eduardo Nunes Salles
- Faculdade de Ciências, Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Jr, 112, São Paulo, SP 01221-020 Brazil
| | - Alexandre Hohl
- Universidade Federal de Santa Catarina (UFSC), Rua Profa. Maria Flora Pausewang, s/n, Florianópolis, SC 88040-970 Brazil
| | - Fábio Trujilho
- Clínica de Endocrinologia e Metabologia, Av. Tancredo Neves, 1632/708, Salvador, BA 41820-020 Brazil
| | - Eduardo Gomes Lima
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | - Marcio Hiroshi Miname
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | | | - Rodrigo Lamounier
- Centro de Diabetes de Belo Horizonte, Rua Niquel, 31, Belo Horizonte, MG 30220-280 Brazil
| | | | - Celso Amodeo
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - Antonio Carlos Pires
- Faculdade de Medicina de São José do Rio Preto, Av. Brg. Faria Lima, 5416, São José do Rio Preto, SP 15090-000 Brazil
| | - Raul D. Santos
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
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Magri CJ, Xuereb RG. Stress echocardiography vs nuclear stress imaging in clinical cardiology. Br J Hosp Med (Lond) 2012; 73:324-30. [DOI: 10.12968/hmed.2012.73.6.324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Stress echocardiography and nuclear stress imaging are important non-invasive tools in clinical cardiology. This review discusses the uses, strengths and limitations of these imaging modalities and looks at whether stress echocardiography can actually replace nuclear stress imaging.
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Affiliation(s)
- Caroline J Magri
- Department of Cardiac Services, Mater Dei Hospital, Tal-Qroqq, Msida MSD 2090
| | - Robert G Xuereb
- Department of Cardiac Services, Mater Dei Hospital, Tal-Qroqq, Msida MSD 2090, Malta
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Abstract
Coronary heart disease (CHD) is the leading cause of morbidity and mortality in patients with diabetes. Asymptomatic CHD in these patients is elusive and carries a poor prognosis given the fact that an unheralded acute myocardial infarction or sudden cardiac death frequently constitutes its first presentation. Because effective screening for asymptomatic patients with type 2 diabetes for both the presence and severity of CHD is intuitively appealing, we have summarized the utility and prognostic value of various diagnostic modalities (both functionally and anatomically) in enhancing risk stratification and leading to improved and more aggressive management of the risk factors. There exist some evidence and recommendations for screening of asymptomatic persons with diabetes using certain modalities. More research is needed to define potential subsets of patients with diabetes who may benefit from additional testing for asymptomatic CHD.
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Affiliation(s)
- Nima Alipour
- Division of Cardiology, Department of Medicine, University of California-Irvine, 333 City Boulevard West, Orange, CA 92868-3298, USA
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7
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Abstract
CLINICAL CONTEXT Sensitive tools are available to diagnose occult ischemic and atherosclerotic coronary disease, yet screening for coronary artery disease (CAD) has not been shown to reduce cardiac events in patients with type 2 diabetes mellitus (T2DM). Professional guidelines are inconsistent regarding CAD screening recommendations, but it is suggested that those at highest risk (10-yr risk ≥20%) for cardiac events may benefit. EVIDENCE ACQUISITION We reviewed bibliographies of professional CAD screening guidelines, review articles, and clinical trials published within the last 10 yr, although we have included relevant older studies. We excluded studies that did not focus on T2DM or explicitly analyze that subgroup. EVIDENCE SYNTHESIS Although screening for coronary ischemia or atherosclerosis does provide incremental prognostic information in patients with T2DM and previously undiagnosed CAD, this has not been found to significantly impact outcomes. This appears to result from comparable efficacy of revascularization and optimal medical therapy in stable CAD. Limited evidence supports the hypothesis that those with more severe CAD (three-vessel, left main, proximal left anterior descending) amenable to bypass surgery may be potential beneficiaries of screening. However, the low prevalence of such candidates in the asymptomatic population, continuing advances with percutaneous intervention, and the lack of prospective trials makes such a recommendation currently unsupportable. CONCLUSIONS Findings to date do not support widespread screening for CAD in patients with T2DM. A future strategy identifying those at highest risk as screening candidates may ultimately be effective, but the optimal method for selecting those subjects or subsequent treatment is unknown.
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Affiliation(s)
- Charles T Upchurch
- University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA.
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Scholte AJHA. Cardiac risk assessment in asymptomatic diabetes: combining [corrected] different imaging modalities and surrogate markers? J Nucl Cardiol 2011; 18:393-5. [PMID: 21448761 PMCID: PMC3095793 DOI: 10.1007/s12350-011-9366-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Arthur J. H. A. Scholte
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, The Netherlands
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Kim MK, Baek KH, Song KH, Kwon HS, Lee JM, Kang MI, Yoon KH, Cha BY, Son HY, Lee KW. Exercise treadmill test in detecting asymptomatic coronary artery disease in type 2 diabetes mellitus. Diabetes Metab J 2011; 35:34-40. [PMID: 21537411 PMCID: PMC3080575 DOI: 10.4093/dmj.2011.35.1.34] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 09/30/2010] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The present study was designed to develop criteria for screening patients with type 2 diabetes mellitus (T2DM) for asymptomatic coronary artery disease (CAD). METHODS A total of 213 patients with T2DM without typical angina or chest pain were studied between 2002 and 2007. We also evaluated 53 patients with T2DM who had reported chest discomfort using an exercise treadmill test (ETT). RESULTS Thirty-one of the 213 asymptomatic patients had positive ETT results. We performed coronary angiography on 23 of the 31 patients with a positive ETT and found that 11 of them had significant coronary stenosis. The main differences between the patients with significant stenosis and those with a negative ETT were age (63.1±9.4 vs. 53.7±10.1 years, P=0.008) and duration of diabetes (16.0±7.5 vs. 5.5±5.7 years, P<0.001). The positive predictive value (PPV) of the ETT was calculated to be 47.8%. The PPV of the ETT increased to 87.5% in elderly patients (≥60 years) with a long duration of diabetes (≥10 years). The latter value is similar to that of patients with T2DM who presented with chest discomfort or exertional dyspnea. The PPV of the ETT in symptomatic patients was 76.9%. CONCLUSION In the interest of cost-effectiveness, screening for asymptomatic CAD could be limited to elderly patients with a duration of diabetes ≥10 years.
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Affiliation(s)
- Mee Kyoung Kim
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Ki Hyun Baek
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Ki Ho Song
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Hyuk Sang Kwon
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Jung Min Lee
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Moo Il Kang
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Kun Ho Yoon
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Bong Yun Cha
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Ho Young Son
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Kwang Woo Lee
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
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Jacqueminet S, Barthelemy O, Rouzet F, Isnard R, Halbron M, Bouzamondo A, Le Guludec D, Grimaldi A, Metzger JP, Le Feuvre C. A randomized study comparing isotope and echocardiography stress testing in the screening of silent myocardial ischaemia in type 2 diabetic patients. DIABETES & METABOLISM 2010; 36:463-9. [PMID: 20832344 DOI: 10.1016/j.diabet.2010.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 06/09/2010] [Accepted: 06/14/2010] [Indexed: 11/18/2022]
Abstract
AIMS This study aimed to compare the positive predictive value (PPV) of stress myocardial scintigraphy (SPECT) and of dobutamine echocardiography (DE) in the diagnosis of significant coronary artery stenosis (CAD) in asymptomatic type 2 diabetic patients, and to assess long-term clinical outcomes according to silent myocardial ischaemia (SMI) screening. METHODS A total of 204 asymptomatic type 2 diabetic patients at high cardiovascular (CV) risk were prospectively randomized to undergo either SPECT (n=104) or DE (n=100). Coronary angiography was proposed in cases of SMI, with revascularization of suitable lesions. Intensive treatment of CV risk factors was prescribed for all patients. Death and myocardial infarction (MI) were recorded during the 3-year follow-up. RESULTS Clinical characteristics were similar in the two testing groups. The prevalence of SMI and significant CAD were 13% and 4%, respectively, in the SPECT group vs 11% and 5%, respectively, in the DE group (not significant [NS]). The PPV for the detection of significant CAD was 29% for SPECT and 45% for DE (NS). Seven patients (3%) underwent initial revascularization. The 3-year rate of CV death and MI was 2.5%, and similar in both groups. CONCLUSION Rates of SMI and significant CAD in asymptomatic high-risk type 2 diabetic patients receiving intensive care of risk factors are low, and SPECT and DE are similar in the detection of SMI and CAD. Coronary revascularization and intensive CV risk-factor therapy are associated with a low rate of adverse CV events at 3 years, whichever stress test was used.
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Affiliation(s)
- S Jacqueminet
- Service de diabétologie, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
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Hiebel A, Fagot-Campagna A, Fosse S, Varroud-Vial M, Weill A, Penfornis A. Feasibility of screening for silent myocardial ischaemia according to the ALFEDIAM–SFC 2004 Guidelines in a population of diabetic patients. DIABETES & METABOLISM 2010; 36:286-92. [DOI: 10.1016/j.diabet.2010.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2009] [Revised: 01/25/2010] [Accepted: 01/27/2010] [Indexed: 10/19/2022]
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Moralidis E, Didangelos T, Arsos G, Athyros V, Mikhailidis DP. Myocardial perfusion scintigraphy in asymptomatic diabetic patients: a critical review. Diabetes Metab Res Rev 2010; 26:336-47. [PMID: 20583311 DOI: 10.1002/dmrr.1098] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The increasing prevalence of diabetes mellitus and the associated high cardiovascular risk has made the non-invasive identification of silent coronary heart disease in diabetic individuals an important issue. This strategy could identify higher risk asymptomatic patients with diabetes mellitus in whom coronary revascularization may improve the outcome beyond that achieved by currently recommended medical management. Stress myocardial perfusion imaging has been shown to be effective in detecting coronary heart disease and predicting adverse cardiac events in asymptomatic diabetic patients. However, the clinical utility of myocardial perfusion scintigraphy is debated intensively due to the paucity of prospective and outcome based evidence. The controversy stems from several observational studies, epidemiologic data and cost-effectiveness analyses. Thus, although several authors and professional organizations advocate the use of stress imaging for screening higher risk asymptomatic diabetic patients, others are cautious in recommending any kind of stress testing in that population. This review is based on a broad survey of the literature and discusses the potential role of stress myocardial perfusion scintigraphy in screening asymptomatic diabetic subjects for coronary heart disease in the current era and in relation with other non-invasive screening tools.
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Affiliation(s)
- E Moralidis
- Department of Nuclear Medicine, AHEPA Hospital, Aristotle University Medical School, Thessaloniki, Greece.
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Wackers FJT, Young LH. Lessons learned from the detection of ischemia in asymptomatic diabetics (DIAD) study. J Nucl Cardiol 2009; 16:855-9. [PMID: 19685266 DOI: 10.1007/s12350-009-9138-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Accepted: 08/02/2009] [Indexed: 01/04/2023]
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Young LH, Wackers FJT, Chyun DA, Davey JA, Barrett EJ, Taillefer R, Heller GV, Iskandrian AE, Wittlin SD, Filipchuk N, Ratner RE, Inzucchi SE. 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. [PMID: 19366774 PMCID: PMC2895332 DOI: 10.1001/jama.2009.476] [Citation(s) in RCA: 552] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
CONTEXT Coronary artery disease (CAD) is the major cause of mortality and morbidity in patients with type 2 diabetes. But the utility of screening patients with type 2 diabetes for asymptomatic CAD is controversial. OBJECTIVE To assess whether routine screening for CAD identifies patients with type 2 diabetes as being at high cardiac risk and whether it affects their cardiac outcomes. DESIGN, SETTING, AND PATIENTS The Detection of Ischemia in Asymptomatic Diabetics (DIAD) study is a randomized controlled trial in which 1123 participants with type 2 diabetes and no symptoms of CAD were randomly assigned to be screened with adenosine-stress radionuclide myocardial perfusion imaging (MPI) or not to be screened. Participants were recruited from diabetes clinics and practices and prospectively followed up from August 2000 to September 2007. MAIN OUTCOME MEASURE Cardiac death or nonfatal myocardial infarction (MI). RESULTS The cumulative cardiac event rate was 2.9% over a mean (SD) follow-up of 4.8 (0.9) years for an average of 0.6% per year. Seven nonfatal MIs and 8 cardiac deaths (2.7%) occurred among the screened group and 10 nonfatal MIs and 7 cardiac deaths (3.0%) among the not-screened group (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.44-1.88; P = .73). Of those in the screened group, 409 participants with normal results and 50 with small MPI defects had lower event rates than the 33 with moderate or large MPI defects; 0.4% per year vs 2.4% per year (HR, 6.3; 95% CI, 1.9-20.1; P = .001). Nevertheless, the positive predictive value of having moderate or large MPI defects was only 12%. The overall rate of coronary revascularization was low in both groups: 31 (5.5%) in the screened group and 44 (7.8%) in the unscreened group (HR, 0.71; 95% CI, 0.45-1.1; P = .14). During the course of study there was a significant and equivalent increase in primary medical prevention in both groups. CONCLUSION In this contemporary study population of patients with diabetes, the cardiac event rates were low and were not significantly reduced by MPI screening for myocardial ischemia over 4.8 years. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00769275.
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Affiliation(s)
- Lawrence H Young
- Yale University School of Medicine, Section of Cardiovascular Medicine, Department of Internal Medicine, New Haven, CT 06520, USA
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15
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Raggi P, Shaw LJ. Screening for Cardiovascular Disease in Symptomatic and Asymptomatic Patients with Diabetes Mellitus. Cardiovasc Endocrinol 2008. [DOI: 10.1007/978-1-59745-141-3_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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16
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Rutter MK, Nesto RW. The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes. ACTA ACUST UNITED AC 2007; 3:26-35. [PMID: 17179927 DOI: 10.1038/ncpendmet0352] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2005] [Accepted: 07/25/2006] [Indexed: 01/06/2023]
Abstract
Aggressive medical therapy can be justified in most patients with diabetes, but there may be some higher-risk asymptomatic patients who could benefit from revascularization and/or medical therapy for myocardial ischemia. Silent myocardial ischemia (SMI) might be used to identify these high-risk individuals. In this Review we define SMI as objective evidence of ischemia from any noninvasive test occurring in an asymptomatic patient. We outline what is known about asymptomatic coronary heart disease (CHD) in diabetes and how this relates to SMI. We examine how SMI predicts angiographic CHD and CHD events, and we describe the changing role of CHD screening as reflected by various guidelines. We identify the recent research suggesting that there may be substantial numbers of high-risk asymptomatic patients who have diabetes with undiagnosed CHD and who could benefit from more-active intervention; however, with the recent advances in medical therapy, and the uncertain benefits of screening, current guidelines strongly discourage this practice, except in limited clinical situations, such as before major surgery. Carefully conducted clinical trails using state-of-the-art investigations and therapy in well-characterized patients with diabetes are urgently required to inform physicians on when and how to intervene.
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Affiliation(s)
- Martin K Rutter
- Diabetes and General Internal Medicine, Manchester Royal Infirmary, Manchester, UK.
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17
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Silent Ischemia. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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18
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Bax JJ, Bonow RO, Tschöpe D, Inzucchi SE, Barrett E. The potential of myocardial perfusion scintigraphy for risk stratification of asymptomatic patients with type 2 diabetes. J Am Coll Cardiol 2006; 48:754-60. [PMID: 16904545 DOI: 10.1016/j.jacc.2006.04.077] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2005] [Revised: 04/06/2006] [Accepted: 04/18/2006] [Indexed: 11/25/2022]
Abstract
Patients with diabetes, in particular patients with type 2 diabetes, are at a 2- to 4-fold higher risk of cardiovascular mortality compared with their nondiabetic peers. Patients with diabetes are also more likely to have silent ischemia and less likely to survive a myocardial infarction than nondiabetic patients. Recent studies with electron beam computed tomography (EBCT) have shown that subclinical atherosclerosis is common in patients with diabetes, and studies with myocardial perfusion scintigraphy (with single-photon emission computed tomography) or stress echocardiography have demonstrated that between 25% and 50% of asymptomatic diabetic patients have ischemia during exercise or pharmacological stress and that a substantial proportion of these patients go on to develop major cardiovascular events within several years. Clearly, asymptomatic diabetic patients include a subset of individuals at high risk of cardiovascular disease who would benefit from improved risk stratification beyond that possible with risk factor scoring systems alone. Single-photon emission computed tomography, stress echocardiography, and possibly EBCT or multi-slice computed tomography, are emerging as valuable diagnostic tools for identifying asymptomatic diabetic patients who might require early and aggressive intervention to manage their cardiovascular risk.
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Affiliation(s)
- Jeroen J Bax
- Leiden University Medical Center, Leiden, The Netherlands.
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19
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Sultan A, Piot C, Mariano-Goulart D, Daures JP, Comte F, Renard E, Avignon A. Myocardial perfusion imaging and cardiac events in a cohort of asymptomatic patients with diabetes living in southern France. Diabet Med 2006; 23:410-8. [PMID: 16620270 DOI: 10.1111/j.1464-5491.2006.01818.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS To assess the association between abnormal stress myocardial perfusion imaging (MPI) and cardiac events (CE) in asymptomatic patients with diabetes and with > or = 1 additional risk factor. Predictors of abnormal stress MPI were also evaluated. METHODS Four hundred and forty-seven consecutive patients who underwent stress MPI were prospectively followed for 2.1 [0.5-4.1] years for the subsequent occurrence of hard CE (myocardial infarction and sudden or coronary death) and soft CE (unstable angina and ischaemic heart failure requiring hospitalization). Re-vascularization procedures performed as a result of the screening protocol were not included in the analysis. RESULTS Follow-up was successful in 419 of 447 patients (94%), of whom 71 had abnormal MPI at baseline. Medical therapy was intensified in all subjects and especially in those with abnormal MPI. Twenty-three patients with abnormal MPI underwent a re-vascularization procedure. CEs occurred in 14 patients, including six of 71 patients (8.5%) with abnormal MPI and eight of 348 patients (2.3%) with normal MPI (P < 0.005). Only two patients developed a hard CE and 12 a soft CE. In multivariate analysis, abnormal MPI was the strongest predictor for CEs [odds ratio (OR) (95% CI) = 5.6 (1.7-18.5)]. Low-density lipoprotein cholesterol > or = 3.35 mmol/l [OR (95% CI) = 7.3; 1.5-34.7] and age > median [OR (95% CI) = 6.0 (1.2-28.6)] were additional independent predictors for CE. The independent predictors for abnormal MPI were male gender, plasma triglycerides > or = 1.70 mmol/l, creatinine clearance < 60 ml/min and HbA1c > 8%, with male gender the strongest [OR (95% CI) = 4.0 (1.8-8.8)]. CONCLUSIONS Asymptomatic patients with diabetes in this study had a very low hard cardiac event rate over an intermediate period. This could be explained by the effects of intervention or by the low event rate in the background population. Randomized studies of cardiac heart disease screening are required in asymptomatic subjects with diabetes to determine the effectiveness of this intervention.
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Affiliation(s)
- A Sultan
- Metabolic Diseases Department, Montpellier University Hospital, Montpellier, France
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20
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Albers AR, Krichavsky MZ, Balady GJ. Stress testing in patients with diabetes mellitus: diagnostic and prognostic value. Circulation 2006; 113:583-92. [PMID: 16449735 DOI: 10.1161/circulationaha.105.584524] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Anne R Albers
- Department of Medicine, Boston Medical Center, Boston University School of Medicine, MA, USA
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21
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Caglar M, Mahmoudian B, Aytemir K, Kahraman S, Arici M, Kabakci G, Karabulut E. Value of 99mTc-methoxyisobutylisonitrile (99mTc-MIBI) gated SPECT for the detection of silent myocardial ischemia in hemodialysis patients: clinical variables associated with abnormal test results. Nucl Med Commun 2006; 27:61-9. [PMID: 16340725 DOI: 10.1097/00006231-200601000-00010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although coronary artery disease is a major cause of mortality and morbidity in patients undergoing hemodialysis, there is no accurate diagnostic strategy for these patients. AIM To assess the value of 99mTc-methoxyisobutylisonitrile (99mTc-MIBI) gated single-photon emission computed tomography for the detection of silent myocardial ischemia in patients undergoing hemodialysis and to evaluate the clinical variables associated with abnormal test results. METHODS Thirty-one asymptomatic patients undergoing hemodialysis (20 men, 11 women), with a mean age of 45 years (range, 25-75 years), were included in the study. Serum electrolytes, creatinine, homocysteine and adhesion molecules were measured prior to dialysis. Ambulatory blood pressure, carotid intima-media thickness measurements, echocardiography and stress 99mTc-MIBI imaging were performed in all patients, whereas coronary angiography was performed only in patients with abnormal myocardial perfusion scintigraphy and/or echocardiography. RESULTS Gated myocardial perfusion scintigraphy results were abnormal in nine patients (29%) and coronary angiography was abnormal in six patients. After a median follow-up of 20 months (range, 14-28 months), nine patients experienced a cardiac event. Seven of the nine patients (78%) with abnormal myocardial perfusion scintigraphy suffered a cardiac event, compared with only two of 22 patients (9%) with normal myocardial perfusion scintigraphy (P<0.0001). Patients with abnormal perfusion scintigraphy had higher serum C-reactive protein, homocysteine and adhesion molecule levels and the duration of hemodialysis was significantly longer. CONCLUSION In asymptomatic hemodialysis patients, gated myocardial perfusion scintigraphy is a safe and non-invasive screening technique for the detection of coronary artery disease and for predicting future cardiac events. The presence of ischemia correlates significantly with markers of inflammation. The discordant results (abnormal myocardial perfusion scintigraphy/normal coronary angiography) can be attributed to angiographically unrecognized occult atherosclerotic changes and abnormal vasodilatation capacity of the coronary circulation.
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Affiliation(s)
- Meltem Caglar
- Department of Nuclear Medicine, Hacettepe University Medical Faculty, Ankara, Turkey.
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22
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Raggi P, Bellasi A, Ratti C. Ischemia imaging and plaque imaging in diabetes: complementary tools to improve cardiovascular risk management. Diabetes Care 2005; 28:2787-94. [PMID: 16249559 DOI: 10.2337/diacare.28.11.2787] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cardiovascular disease is the most frequent cause of death and disability in diabetes, and the morbidity and mortality for coronary artery disease (CAD) in this population is two to four times higher than in nondiabetic subjects. Traditional risk factors do not fully explain the level of cardiovascular risk, and coronary disease events are often silent in diabetic patients. Thus, research has recently focused on improving the risk assessment of an individual patient with new tools in an effort to better identify subjects at highest risk and in need of aggressive management. Cardiovascular imaging has proven very helpful in this regard. Traditional methods to assess CAD are based on detection of obstructive luminal disease responsible for myocardial ischemia. However, acute coronary syndromes often occur in the absence of luminal stenoses. Hence, the utilization of imaging methodologies to visualize atherosclerosis in its presymptomatic stages has received mounting attention in recent years. In this article, we review the current literature on the utility of traditional imaging modalities for obstructive CAD (nuclear and echocardiographic stress testing) as well as atherosclerosis plaque imaging with carotid intima-media thickness and coronary artery calcium for risk stratification of diabetic patients.
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Affiliation(s)
- Paolo Raggi
- Section of Cardiology, Tulane University School of Medicine, Tulane University, New Orleans, LA 70112, USA.
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23
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Cosson E, Attali JR, Valensi P. Markers for silent myocardial ischemia in diabetes. Are they helpful? DIABETES & METABOLISM 2005; 31:205-13. [PMID: 15959427 DOI: 10.1016/s1262-3636(07)70187-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Silent myocardial ischemia (SMI) and silent coronary stenoses (CS) are two to seven times more frequent in diabetic patients than in non-diabetic patients. In addition to this, they have a higher predictive value for cardiovascular events than the classical cardiovascular risk factors, either taken alone or combined. Coronary arterial disease is the leading cause of mortality and morbidity in the diabetic population. Altogether, these data suggest that screening for SMI and silent CS is an important issue. We assume that detecting SMI and silent CS improves patient management, and leads to optimised follow-up, action taken on nutrition, exercise and lifestyle, management of the cardiovascular risk factors, and revascularisation procedures whenever possible. However, screening for SMI and silent CS is expensive and may induce morbidity. Selecting the patients with a high a priori risk of SMI and silent CS is therefore of major concern. Carotid or lower limb peripheral arterial disease, proteinuria, male gender, an age greater than 60 years, and two or more cardiovascular risk factors among smoking, microalbuminuria, dyslipidemia, hypertension, a family history of premature cardiac disease, and cardiac autonomic neuropathy have been demonstrated to be the best current predictors of SMI and silent CS. New markers, such as adhesion molecules, Lp(a), inflammation parameters or homocysteine, and endothelium function assessment might be of further help in the future.
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Affiliation(s)
- E Cosson
- Department of Endocrinology-Diabetology-Nutrition, Paris-Nord University, Jean Verdier Hospital, AP-HP, Bondy, France.
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24
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Le Feuvre CL, Barthélémy O, Dubois-Laforgue D, Maunoury C, Mogenet A, Baubion N, Metzger JP, Timsit J. Stress myocardial scintigraphy and dobutamine echocardiography in the detection of coronary disease in asymptomatic patients with type 2 diabetes. DIABETES & METABOLISM 2005; 31:135-42. [PMID: 15959419 DOI: 10.1016/s1262-3636(07)70179-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aims of this prospective study were: (1) to compare stress thallium-201 single photon emission computed tomography (SPECT) and dobutamine echocardiography (DE) in the detection of silent myocardial ischemia (SMI) in asymptomatic high risk diabetic patients; (2) to analyse long-term outcome after intensive care of SMI in these patients. METHODS SPECT was performed in 100 high risk diabetic patients and DE in the first 75 patients. Coronary angiography was realized in patients with SMI, with revascularization for suitable lesions. Intensive treatment of atherosclerosis risk factors was performed in all patients. Patients were followed 2 +/- 0.5 years for the subsequent occurrence of cardiac death, myocardial infarction and revascularization. RESULTS SMI was detected by SPECT in 62% and by DE in 10% of the patients (p < 0.0001), whereas significant coronary stenosis at angiography was detected by SPECT in 26% and by DE in 5% of the patients (p < 0.02). Independent predictive factors of significant coronary stenosis were male gender (p < 0.03) and peripheral arterial disease (p < 0.007). Nonfatal acute coronary syndrome occurred during follow-up in 2 patients (2%). Subsequent revascularization procedure was needed in 9 patients. Baseline patients' characteristics, as well as SMI, were not predictive of cardiac event during follow up. CONCLUSION SPECT seems more accurate than DE to detect significant coronary stenosis in high risk asymptomatic diabetic patients. In this population, aggressive treatment of SMI with systematic revascularization combined with intensive care of risk factors is associated with a favorable long-term prognosis, similar in diabetic patients with and without initial SMI.
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Affiliation(s)
- Cl L Le Feuvre
- Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, France.
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25
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Elhendy A, Tsutsui JM, O'Leary EL, Xie F, McGrain AC, Porter TR. Noninvasive diagnosis of coronary artery disease in patients with diabetes by dobutamine stress real-time myocardial contrast perfusion imaging. Diabetes Care 2005; 28:1662-7. [PMID: 15983317 DOI: 10.2337/diacare.28.7.1662] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to assess the accuracy of real-time myocardial contrast perfusion imaging (MCPI) during dobutamine stress in the diagnosis and localization of coronary artery disease (CAD) in patients with diabetes. Myocardial contrast echocardiography is a new technique that allows evaluation of myocardial perfusion. Its utility in diabetic patients has not been defined. RESEARCH DESIGN AND METHODS Dobutamine-atropine stress test was performed in conjunction with MCPI using Optison or Definity at rest and at peak stress in 128 patients with diabetes and suspected CAD who underwent coronary angiography within 1 month. CAD was defined as > or =50% stenosis in one or more coronary artery. MCPI was considered diagnostic of CAD in the presence of reversible perfusion abnormalities. The normalcy rate of MCPI was additionally determined in 18 asymptomatic nondiabetic patients with low probability. RESULTS CAD was detected in 101 (79%) patients by angiography. Reversible perfusion abnormalities were detected in 90 patients with and 13 patients without CAD. The overall sensitivity of MCPI was 89% (95% CI 83-95), specificity 52% (33-71), and accuracy 81% (75-88). Reversible abnormalities were detected in two or more vascular distributions in 44 of 56 patients with multivessel CAD and in 8 of 63 patients without (sensitivity 68%, specificity 87%, positive predictive value 84%, and accuracy 79%). Regional sensitivity was 75% (65-85) for left anterior descending CAD, 71% (60-83) for left circumflex, and 67% (55-78) for right CAD. MCPI was normal in 16 of the 18 patients with low clinical probability of CAD (normalcy rate 89%). CONCLUSIONS MCPI is a useful noninvasive technique for the diagnosis and localization of CAD in diabetic patients. The extent of perfusion abnormalities can identify patients with multivessel CAD with a moderate sensitivity and high specificity.
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Affiliation(s)
- Abdou Elhendy
- Department of Internal Medicine, Section of Cardiology, University of Nebraska Medical Center, Omaha, NE 68198-2265, USA.
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Senior PA, Welsh RC, McDonald CG, Paty BW, Shapiro AMJ, Ryan EA. Coronary artery disease is common in nonuremic, asymptomatic type 1 diabetic islet transplant candidates. Diabetes Care 2005; 28:866-72. [PMID: 15793187 DOI: 10.2337/diacare.28.4.866] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Coronary artery disease (CAD) is the most common cause of death in patients with type 1 diabetes. Asymptomatic CAD is common in uremic diabetic patients, but its prevalence in nonuremic type 1 diabetic patients is unknown. The prevalence of CAD was determined by coronary angiography and the performance of noninvasive cardiac investigation evaluated in type 1 diabetic islet transplant (ITX) candidates with preserved renal function. RESEARCH DESIGN AND METHODS A total of 60 consecutive type 1 diabetic ITX candidates (average age 46 years [mean 24-64], 23 men, and 47% ever smokers) underwent coronary angiography, electrocardiographic stress testing (EST), and myocardial perfusion imaging (MPI) in a prospective cohort study. CAD was indicated on angiography by the presence of stenoses >50%. Models to predict CAD were examined by logistic regression. RESULTS Most subjects (53 of 60) had no history or symptoms of CAD; 23 (43%) of these asymptomatic subjects had stenoses >50%. CAD was associated with age, duration of diabetes, hypertension, and smoking. Although specific, EST and MPI were not sensitive as predictors of CAD on angiography (specificity 0.97 and 0.93, sensitivity 0.17 and 0.04, respectively) but helped identify two of three subjects requiring revascularization. EST and MPI did not enhance logistic regression models. A clinical algorithm to identify low-risk subjects who may not require angiography was highly sensitive but was applicable only to a minority (n = 8, sensitivity 1.0, specificity 0.27, negative predictive value 1.0). CONCLUSIONS Nonuremic type 1 diabetic patients with hypoglycemic unawareness and/or metabolic lability referred for ITX are at high risk for asymptomatic CAD despite negative noninvasive investigations. Aggressive management of cardiovascular risk factors and further investigation into optimal cardiac risk stratification in type 1 diabetes are warranted.
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Affiliation(s)
- Peter A Senior
- Clinical Islet Transplant Program, University of Alberta, 8215 112th St., Edmonton, Alberta, Canada T6G 2C8.
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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. [PMID: 15629371 DOI: 10.1016/j.jacc.2004.06.078] [Citation(s) in RCA: 164] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2003] [Revised: 05/14/2004] [Accepted: 06/23/2004] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The purpose of this study was to identify which asymptomatic diabetic patients are candidates for screening single-photon emission computed tomography (SPECT) imaging and to examine angiographic findings and mortality in patients according to SPECT imaging categories. BACKGROUND Previously we reported a high percentage of abnormal and high-risk SPECT imaging scans in asymptomatic diabetic patients. METHODS We examined the associations between several clinical and laboratory variables and a high-risk stress SPECT imaging scan in 1,427 asymptomatic diabetic patients without known coronary artery disease (CAD). Results of coronary angiography and long-term outcome were also analyzed. RESULTS An abnormal stress SPECT imaging scan was present in 826 patients (58%) and a high-risk scan in 261 patients (18%). Multivariate analysis demonstrated that seven variables were independently associated with a high-risk scan (model chi-square=107, p <0.0001). The two most important variables were electrocardiogram (ECG) Q waves (adjusted chi-square=38.3, p <0.001) and peripheral arterial disease (PAD) (adjusted chi-square=13.9, p <0.001). Coronary angiography was performed in 127 (49%) high-risk SPECT imaging patients, 61% of whom had angiographic high-risk CAD. Annual mortality rates for patient subsets categorized by SPECT imaging scans were high-risk 5.9%, intermediate-risk 5.0%, and low-risk 3.6% (p <0.001 for differences between groups). CONCLUSIONS High-risk findings on stress SPECT imaging were present in 18% of asymptomatic diabetic patients without known CAD. Patients with high-risk scans had a high prevalence of severe CAD and a high annual mortality rate. ECG Q waves and/or evidence of PAD identified the most suitable candidates for screening.
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Affiliation(s)
- Navin Rajagopalan
- Department of Internal Medicine and Cardiovascular Diseases, Mayo, Rochester, MN 55905, USA
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28
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Miller TD, Rajagopalan N, Hodge DO, Frye RL, Gibbons RJ. Yield of stress single-photon emission computed tomography in asymptomatic patients with diabetes. Am Heart J 2004; 147:890-6. [PMID: 15131547 DOI: 10.1016/j.ahj.2003.08.015] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with diabetes without clinically apparent coronary artery disease are at increased risk of cardiac death. The value of screening stress testing in these patients remains controversial. The goal of this study was to examine the yield of stress single-photon emission computed tomography (SPECT) in asymptomatic diabetic patients. METHODS The results of stress SPECT in patients without prior myocardial infarction or coronary revascularization were compared in asymptomatic diabetics (n = 1738) versus symptomatic diabetic patients (n = 2998), asymptomatic nondiabetic patients (n = 6215), and symptomatic nondiabetic patients (n = 16,214). RESULTS Abnormal scans were present in 58.6% of asymptomatic diabetic patients, approximately equal to the percentage in symptomatic diabetic (59.5%) (P = not significant) and higher than in asymptomatic nondiabetic (46.2%) (P <.001) and symptomatic nondiabetic (44.4%) (P <.001) patients. The breakdown of high-risk scans followed a similar pattern in the 4 patient subsets: asymptomatic diabetic, 19.7% versus symptomatic diabetic, 22.2% (P =.051); asymptomatic nondiabetic, 11.1% (P <.001); and symptomatic nondiabetic, 12.5% (P <.001). Patients with diabetes had more electrocardiographic and scan evidence for silent myocardial infarction versus those without diabetes. CONCLUSIONS Asymptomatic diabetic patients have a high prevalence of both abnormal and high-risk SPECT scans. The finding that approximately 1 in 5 of these individuals has a high-risk scan suggests a potentially more widespread application of screening stress SPECT in asymptomatic diabetic patients to identify those with severe coronary artery disease.
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Affiliation(s)
- Todd D Miller
- Department of Internal Medicine and Cardiovascular Disease, Rochester, Minn, USA.
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Cosson E, Paycha F, Paries J, Cattan S, Ramadan A, Meddah D, Attali JR, Valensi P. Detecting silent coronary stenoses and stratifying cardiac risk in patients with diabetes: ECG stress test or exercise myocardial scintigraphy? Diabet Med 2004; 21:342-8. [PMID: 15049936 DOI: 10.1111/j.1464-5491.2004.01157.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS To determine whether performing a myocardial scintigraphy immediately after a maximal electrocardiogram (ECG) stress test is effective in detecting silent coronary stenoses and predicting cardiovascular events. METHODS Asymptomatic patients (n = 262) aged 57.6 +/- 8.8 years, with diabetes for 12.0 years (5-39) [median (range)] and no history of a cardiac event, underwent a maximal ECG stress test followed by a myocardial scintigraphy. The patients with an abnormal ECG stress test or abnormal imaging underwent a coronary angiography. Cardiac events were assessed in 250 (95.4%) patients followed for 37.8 months (3-101). RESULTS The ECG stress test was abnormal in 54 patients. Among them, 18 had coronary stenoses and seven had a cardiac event. Despite a normal ECG stress test, the myocardial scintigraphy was abnormal in 42 additional patients, including 16 patients with coronary stenoses. Four of these 42 patients experienced a cardiac event. Follow-up showed a poor prognosis in subjects who were abnormal on the two tests. Univariate predictors of the 15 cardiac events were the ECG stress test [odds ratio (OR) 3.9, 95% confidence interval (CI) 1.3, 11.4, P = 0.008], myocardial scintigraphy (OR 3.8, 95% CI 1.3, 11.0, P = 0.009), coronary stenoses (OR 26.6, 95% CI 7.6, 90.7, P < 0.001), and peripheral or carotid occlusive arterial disease (OR 9.5, 95% CI 2.1, 42.5, P < 0.001). CONCLUSIONS In the asymptomatic patients with diabetes, combining a myocardial scintigraphy with a maximal ECG stress test is effective in detecting more patients with coronary stenoses and predicting cardiovascular events. However, the ECG stress test has a good negative predictive value for cardiac events (97%), is cheaper, and should therefore be proposed first.
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Affiliation(s)
- E Cosson
- Department of Endocrinology-Diabetology-Nutrition, AP-HP, Paris-Nord University, Jean Verdier Hospital, Bondy, France.
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Abstract
Effective diagnosis and treatment of coronary artery disease (CAD) are key to the management of patients with diabetes. Although the use of specialized cardiac testing for CAD screening in asymptomatic patients varies widely and is the source of current controversy, evidence is emerging on the prevalence and predictors of asymptomatic ischemia in diabetic patients. Accurate diagnosis and risk stratification are essential in symptomatic patients with known or suspected CAD. Noninvasive cardiac testing has an important role in these patients, although evaluation for revascularization with cardiac catheterization is warranted in high-risk circumstances. This article reviews recent information that may help guide the clinician in the appropriate use of cardiac testing in diabetic patients.
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Affiliation(s)
- Lawrence H Young
- Department of Internal Medicine (Section of Cardiovascular Medicine), Yale University School of Medicine, 333 Cedar Street, 3 FMP, New Haven, CT 06520, USA.
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Rutter MK, Wahid ST, McComb JM, Marshall SM. Significance of silent ischemia and microalbuminuria in predicting coronary events in asymptomatic patients with type 2 diabetes. J Am Coll Cardiol 2002; 40:56-61. [PMID: 12103256 DOI: 10.1016/s0735-1097(02)01910-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the relationships between future coronary heart disease (CHD) events and baseline silent myocardial ischemia (SMI) and microalbuminuria (MA) in subjects with type 2 diabetes (T2D) free from known CHD. BACKGROUND Coronary heart disease is often asymptomatic in subjects with diabetes. There is limited information on the prognostic value of SMI and MA in this group. METHODS Eighty-six patients with T2D and no history of CHD were studied (43 with MA individually matched with 43 normoalbuminuric patients; mean [SD] age 62 [+/-7] years, 62 men). Metabolic assessment, three timed overnight urine collections for albumin excretion rate, a treadmill exercise test and ankle brachial index (ABI) were performed at baseline. Patients were followed for 2.8 years. RESULTS Forty-five (52%) patients had SMI during treadmill testing. At review, there had been 23 coronary (CHD) events in 15 patients. Univariate Cox regression analysis showed that CHD events were significantly related to baseline ABI (p = 0.014), SMI (p = 0.020), MA (p = 0.046), 10-year Framingham CHD risk >30% (p = 0.035) and fibrinogen (p = 0.026). In multivariate analysis, SMI was the strongest independent predictor of CHD events (p = 0.008); risk ratio (95% confidence interval) for SMI: 21 (2 to 204). In the prediction of CHD events, SMI showed higher sensitivity and positive predictive value than MA or Framingham calculated CHD risk. CONCLUSIONS The presence of baseline SMI and MA are associated with future CHD events in asymptomatic patients with T2D and may be of practical use in risk stratification.
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Affiliation(s)
- Martin K Rutter
- Department of Medicine, University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom.
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Current literature in diabetes. Diabetes Metab Res Rev 2002; 18:162-9. [PMID: 11994909 DOI: 10.1002/dmrr.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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