Detection of occult coronary artery disease in asymptomatic individuals with diabetes mellitus using non-invasive cardiac angiography

doi:10.1016/j.atherosclerosis.2008.07.030

Atherosclerosis

Volume 203, Issue 2, April 2009, Pages 442-448

https://doi.org/10.1016/j.atherosclerosis.2008.07.030 Get rights and content

Abstract

Introduction/objectives

Cardiovascular disease is the leading cause of death for individuals with diabetes mellitus. Controversy exists regarding the screening of asymptomatic diabetics for occult coronary artery disease (CAD). The purpose of this study is to describe the prevalence of occult CAD in a group of asymptomatic subjects with diabetes using non-invasive coronary angiography, as well as to investigate the predictive accuracy of current guidelines with regards to their recommended criteria for further cardiac diagnostic testing in this patient population.

Methods

We prospectively enrolled 217 asymptomatic Korean outpatients with type 2 diabetes who had no prior history of CAD. All underwent non-invasive coronary angiography using a 64-slice multi-detector computed tomography scanner.

Results

The mean age of the study participants was 59 ± 8 years; 66% were men. Diabetes duration was 7 ± 7 years, mean Framingham risk score was 13%, and mean hemoglobin A1C level was 7%. Of the 217 outpatients, 138 (64%) had occult CAD based on cardiac computed tomography angiography (CCTA) findings. Thirty-six (36/138; 26%) had a significant stenosis on CCTA. Nearly half of the individuals (62/138; 45%) had a combination of non-calcified and calcified plaques. Only 5 out of 217 (2%) individuals with significant stenosis would have been missed using the American Diabetes Association (ADA) criteria for further cardiac testing.

Conclusion

Almost two thirds of asymptomatic diabetics have occult CAD, including obstructive disease. Based on CCTA findings, the ADA criteria for further cardiac diagnostic testing would identify most individuals who have a significant coronary stenosis.

Introduction

More than 200 million people worldwide have diabetes. The estimated prevalence for 2025 surpasses the 300 million mark [1]. Approximately 80% of diabetics die of cardiovascular disease [1] and in general tend to have more extensive atherosclerosis with a higher prevalence of diffuse disease, more frequent silent myocardial ischemia, and a higher cardiac event rate than non-diabetic individuals [2], [3], [4].

The role of enhanced risk stratification using non-invasive imaging studies in asymptomatic diabetic subjects remains a controversial issue. Although current guidelines by the American Diabetes Association (ADA) suggest that only those individuals with multiple cardiovascular risk factors should undergo further diagnostic work-up, several recent studies have shown that the burden of traditional risk factors does not accurately predicts inducible ischemia on nuclear or echocardiographic myocardial stress imaging [5], [6], [7]. Whether asymptomatic diabetic subjects with significant coronary stenosis benefit or not from revascularization, remains to be seen.

Cardiac computed tomography angiography (CCTA) has emerged as a valid alternative imaging modality for the evaluation of patients with known or occult coronary artery disease (CAD) [8]. The 64-slice CCTA scanner has been shown to be a sensitive and specific tool for the detection of significant coronary stenoses, and has been validated against conventional coronary angiography and intravascular ultrasound [9], [10], [11], [12], [13], [14]. Due to the multiple strengths of this technology, CCTA could theoretically be a useful tool for further risk stratifying asymptomatic diabetic subjects.

The purpose of this study was to describe the prevalence of occult CAD in a group of South Korean adults with diabetes, with particular attention to distinguishing non-obstructive from obstructive disease. We also evaluated the predictive accuracy of current ADA guidelines, which recommend further cardiac testing in those individuals with multiple traditional risk factors. In addition, we assessed the adequacy of the ADA criteria with regards to its accuracy to identify those individuals that had at least one significant (>50%) coronary stenosis.

Section snippets

Study population

We prospectively enrolled 217 South Korean subjects with type 2 diabetes who were evaluated in an outpatient clinic affiliated to the Seoul National University Bundang Hospital from November 2006 to June 2007. Individuals between the ages of 45–75 years were included in the study. Diabetes was defined as having a history of diabetes and/or receiving anti-diabetic treatment, or meeting WHO criteria [15].

Exclusion criteria were: (1) insulin pump treatment or history of diabetic ketoacidosis, (2)

Results

The characteristics of the study participants are illustrated in Table 1. The mean age was 59 ± 8 years (66% males). The mean duration of diabetes was 7 ± 7 years and the mean hemoglobin A1C was 7%. A significant percentage of the individuals were hypertensive (69%) and had dyslipidemia (78%). The average Framingham risk score was 13%. Nine percent of the subjects were treated for their diabetes with lifestyle modifications, 80% with oral hypoglycemic agents, and 11% with insulin. Forty two percent

Discussion

A high percentage (64%; 138/217) of asymptomatic South Korean individuals with diabetes had occult CAD as evidenced by CCTA. Furthermore, 26% (36/138), or 17% (36/217) of the overall population, had significant coronary artery stenosis. Fig. 2 illustrates CCTA and invasive coronary angiography results for a 59-year-old man. Prior perfusion studies conducted in an asymptomatic diabetic patient population have yielded similar results [7].

To date, there is little evidence on the presence of occult

Conclusions

A high percentage of asymptomatic diabetic individuals have occult CAD, including obstructive disease. Most individuals with CAD have a plaque burden composition characterized by the combination of the different types of plaques. Individuals with a higher CACS tend to have more significant disease. The ADA criteria, used to identify those individuals that would benefit from further cardiac testing, is adequate, missing only 2% of the subjects in our study population who had a significant

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Detection of occult coronary artery disease in asymptomatic individuals with diabetes mellitus using non-invasive cardiac angiography

Abstract

Introduction/objectives

Methods

Results

Conclusion

Introduction

Section snippets

Study population

Results

Discussion

Conclusions

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Angina and exertional myocardial ischemia in diabetic and non-diabetic patients: assessment by exercise thallium scintigraphy

Ann Intern Med

Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial

Diabetes Care