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.
Highlights
There is increasing evidence to suggest that not all individuals with type 2 diabetes mellitus (T2DM) have equal risk for developing cardiovascular disease
Using coronary computed tomography angiography (CTA) as the reference standard, we sought to compare the use of coronary artery calcium (CAC) scoring, carotid ultrasound, and exercise treadmill testing (ETT) for detecting subclinical coronary artery disease (CAD) among a cohort of asymptomatic patients with diabetes
In this study of asymptomatic diabetic subjects without known cardiovascular disease, we showed that there is a substantial heterogeneity in the prevalence of subclinical coronary disease, as only 44 % of subjects had evidence of any plaque by coronary CTA and only 16 % had obstructive CAD
Summary
There is increasing evidence to suggest that not all individuals with type 2 diabetes mellitus (T2DM) have equal risk for developing cardiovascular disease. Despite the lack of proven benefit, there may remain a role for screening selected individuals with diabetes, if the test results could favorably influence downstream medical and lifestyle therapies Such screening approaches could be useful to provide more individualized assessment when deciding on the intensity of statin therapy, the role of aspirin [12], or potentially in the future, the role of anti-inflammatory therapies [13] and newer lipid lowering agents [14]. Multiple imaging and laboratory techniques are available to detect the presence of pre-clinical disease and characterize an individual’s risk of future cardiovascular events It remains uncertain how each of these approaches compare to each other and to more expensive imaging techniques in the risk stratification of individuals with T2DM. Using coronary computed tomography angiography (CTA) as the reference standard, we sought to compare the use of coronary artery calcium (CAC) scoring, carotid ultrasound, and exercise treadmill testing (ETT) for detecting subclinical CAD among a cohort of asymptomatic patients with diabetes
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