Asymptomatic Diabetic Patients Research Articles

A study of cardiac changes in asymptomatic diabetic patients in comparison with normal population

Background: India is predicted to bear the greatest Coronary artery disease (CAD) burden, according to the estimates from the global burden of disease study. Majority of the time the patient of diabetes presents with complications like Myocardial infarction (MI), heart failure, being end stages of cardiovascular disease associated with other macro and micro-vascular complications.Methods: This study was done in view of screening the asymptomatic diabetic individuals presenting to our hospital for any evidence of early cardio-vascular manifestations. With the aid of non-invasive testing such as electrocardiography (ECG) and 2D echo the early changes were noted and compared with the normal population and the cardiac status thus evaluated. A total of 106 patients (53 were diabetic and 53 non-diabetic controls) were included in the study in order to compare the ECG and 2D echo findings among the population. The main aim of the present study was to observe the ECG manifestations in diabetic patients without overt symptoms of any cardiac disease and to evaluate the ECG changes along with 2D echocardiogram in asymptomatic diabetic patients and compare with normal population.Results: From the study, it was observed that majority among the diabetic population were found to have statistically significant changes in the ECG like PR interval prolongation, T wave inversions and QT interval prolongation. 2D ECHO studied showed the presence of Left ventricular diastolic dysfunction and Regional wall motion abnormalities to be evident among the diabetic population.Conclusions: It was concluded from the study that diabetic patients have a higher risk of cardiovascular morbidities compared to the general population and ECG changes are observed even when they are clinically asymptomatic. This observation has been confirmed by the 2D echo findings. It is essential to screen diabetic patients at an early stage to prevent cardiovascular complications. ECG being a relatively cheap and non-invasive investigation should be utilized to screen diabetics for the same.

Peripheral arterial disease of the lower limbs in asymptomatic diabetic patients: Prevalence and determining factors

Peripheral arterial disease (PAD) of the lower limbs is an important predictor of cardiovascular disease; however it's still underdiagnosed over asymptomatic diabetic patients, free of cardiovascular disease. Determining the prevalence and risk factors for PAD in an asymptomatic population of diabetic patients at low or intermediate risk factors of cardiovascular disease, with a free history of cardiovascular disease. This was a prospective study conducted over 14 months period from November 2017 to January 2018. A total of 309 diabetic patients were included from two diabetes centers. PAD was defined as an ankle-brachial index (ABI) less than 0,9. Among the 309 patients, the ankle-brachial index (ABI) was < 0.9 in 98 (31,71%) patients considered to have PAD. The ABI was > 1.3 in 36 (11,35%) patients who had suspected mediacalcosis. The average age of the PAD population was 56.2 years. Female gender predominated (57%). The mean duration of diabetes was 11 yeras: 80% type II Diabetes. PAD of the lower limbs was mild in 26 patients (26,53%) moderate in 49 (50%) and severe in 23 (23,46%). Duplex Doppler commonly showed lesions of the femoral and tibial arteries. Factors associated with PAD were advanced age ( P < 0.0001), age of diabetes > 6 years ( P < 0.0001), uncontrolled diabetes as assessed by HbA1c levels > 7% ( P < 0), 0001) and elevated fasting glucose levels ( P = 0.039), Hypertension ( P < 0.0001) and dyslipidemia ( P < 0.0001). For mediacalcosis, male gender was the only factor identified. Primary prevention outpatient screening of asymptomatic diabetic patients with lower or intermediate cardiovascular risk can identify numerous patients with PAD. Advanced age, a mean duration of diabetes over 6years, uncontrolled diabetes, hypertension, and dyslipidemia were predictive factors for diabetic PAD of the lower limbs in our population.

Progression of coronary atherosclerotic plaque burden and relationship with adverse cardiovascular event in asymptomatic diabetic patients

BackgroundThe heterogeneity of risk in patients with diabetes mellitus (DM) is acknowledged in new guidelines promulgating different treatment recommendations for diabetics at low cardiac risk. We performed a retrospective longitudinal follow-up study to evaluate coronary plaque progression and its impact on cardiac events in asymptomatic diabetic patients.MethodsData of 197 asymptomatic patients (63.1 ± 17 years, 60% males) with DM and suspected coronary artery disease (CAD) who underwent clinically indicated dual-source cardiac computed tomography (CT) were retrospectively analyzed. Patients with DM received standard of care treatment. Patients were classified into two groups based on CT coronary artery calcium scores (CACS): A, CACS> 10; B, CACS≤10. Progression of coronary plaque burden in both groups was evaluated and compared by baseline and follow-up coronary CT angiography (CCTA) using semi-automated plaque analysis and quantification software. Follow-up data were retrospectively gathered from medical records and endpoints of cardiac events were recorded via prospective phone-calls. The impacts of plaque composition and progression on cardiac events were specifically assessed.ResultsPatients with CACS> 10 showed an increase in dense coronary calcium volume, while patients with CACS≤10 had a more pronounced increase in the volume of low-attenuation “lipid-rich” plaque components between CCTA acquisitions. The composite endpoint occurred in 20 patients (10.2%) after a median follow-up period of 41.8 months. Furthermore, at follow-up CCTA, the presence of CACS> 10 (adjusted odds ratio, 0.701; 95% CI, 0.612–0.836), increase of dense calcium volume (OR, 0.860 95% CI, 0.771–0.960), and lipid volume (OR, 1.013; 95% CI, 1.007–1.020) were all independent predictors of cardiac events.ConclusionAsymptomatic patients with DM experienced plaque progression as well as progression to “overt or silent CAD”. The relative increase in plaque volume was associated with subsequent cardiac events, and the coronary calcification seemed to be inversely related to the outcome in asymptomatic diabetic patients.

Screening and Risk Assessment of Coronary Artery Disease in Patients With Type 2 Diabetes: An Updated Review.

Current literature indicates that there is a strong correlation between coronary artery disease (CAD) and type 2 diabetes. The arteriosclerotic progression occurs earlier and in a greater extent in the diabetic than in the non-diabetic population. In diabetic subjects, the detection of arterial disease does not always precede the development of an acute arterial incident. Herein, we reviewed studies published within the last 5 years in order to reveal the risk factors for coronary artery disease in patients with type 2 diabetes. In addition, we aimed to discuss how to diagnose in an early stage or even screen the presence of coronary artery disease in asymptomatic diabetic patients. Possible blood markers as predictors of CAD, which are mostly related to the lipidemic profile of subjects, are included in this review. Less invasive imaging methods than conventional coronary angiography, included in the article, are gradually used more in the diagnosis of CAD and show high effectiveness. Data from 23 articles with 22,350 patients having type 2 diabetes were summarized and presented descriptively.

Screening of silent myocardial ischemia in asymptomatic diabetic patients: ROle of coronary artery calcium and stress myocardial perfusion scintigraphy

Coronary artery diseases and heart failure are the main causes of morbimortality in diabetes. Screening of silent myocardial ischemia in asymptomatic diabetic patients is very important and is still controversial. Coronary artery calcium (CAC) belongs to innovative technology in non-invasive imagery technique based on tomography without injection and permits cardiovascular risk assessment; its threshold usually is 400. Principal objective was to diagnose silent myocardial ischemia in asymptomatic diabetics based on CAC measurement. A secondary objective was to determine patients’ characteristics when CAC was < or ≥ 400. CAC imaging was performed in every asymptomatic diabetic patient and all patients with CAC ≥ 400 underwent myocardial perfusion scintigraphy. Two hundred and sixty-three patients were included between 2014 and 2017. Eighty patients had a CAC score ≥ 400 and sixty-two of them underwent myocardial perfusion scintigraphy. Silent myocardial ischemia was detected in 14 patients (5%). The predictors of elevated CAC were: age, male gender, hypertension, duration of diabetes, dyslipidemia and microalbuminuria. In this study, evaluating silent ischemia screening, CAC followed by myocardial scintigraphy have an important role in cardiovascular risk assessment. Thirty percent of patients required an imaging test such as perfusion scintigraphy and 5% had silent myocardial ischemia. CAC and myocardial perfusion scintigraphy can improve screening and risk stratification in this population. CAC score can help to guide medical treatment.

Mitochondrial NAD+/NADH Redox State and Diabetic Cardiomyopathy.

Significance: Diabetic cardiomyopathy (DCM) is a frequent complication occurring even in well-controlled asymptomatic diabetic patients, and it may advance to heart failure (HF).Recent Advances: The diabetic heart is characterized by a state of “metabolic rigidity” involving enhanced rates of fatty acid uptake and mitochondrial oxidation as the predominant energy source, and it exhibits mitochondrial electron transport chain defects. These alterations promote redox state changes evidenced by a decreased NAD+/NADH ratio associated with an increase in acetyl-CoA/CoA ratio. NAD+ is a co-substrate for deacetylases, sirtuins, and a critical molecule in metabolism and redox signaling; whereas acetyl-CoA promotes protein lysine acetylation, affecting mitochondrial integrity and causing epigenetic changes.Critical Issues: DCM lacks specific therapies with treatment only in later disease stages using standard, palliative HF interventions. Traditional therapy targeting neurohormonal signaling and hemodynamics failed to improve mortality rates. Though mitochondrial redox state changes occur in the heart with obesity and diabetes, how the mitochondrial NAD+/NADH redox couple connects the remodeled energy metabolism with mitochondrial and cytosolic antioxidant defense and nuclear epigenetic changes remains to be determined. Mitochondrial therapies targeting the mitochondrial NAD+/NADH redox ratio may alleviate cardiac dysfunction.Future Directions: Specific therapies must be supported by an optimal understanding of changes in mitochondrial redox state and how it influences other cellular compartments; this field has begun to surface as a therapeutic target for the diabetic heart. We propose an approach based on an alternate mitochondrial electron transport that normalizes the mitochondrial redox state and improves cardiac function in diabetes.

Two-dimensional left atrial and left ventricular function in asymptomatic diabetic patients

Two-dimensional left atrial and left ventricular function in asymptomatic diabetic patients

Serum bilirubin improves the risk predictions of cardiovascular and total death in diabetic patients

BackgroundBilirubin is a potential endogenous inhibitor of atherosclerosis. We investigated the association of bilirubin and cardiovascular (CV) and all-cause mortality including potential improvements in bilirubin risk reclassification in asymptomatic diabetic patients. MethodsWe enrolled 2936 asymptomatic diabetic subjects. The serum bilirubin was measured, and future CV and all-cause death were the primary endpoints. ResultsThe follow-up period was 5.4 ± 3.0 y. There were 218 deaths including 95 cardiovascular deaths. The occurrence of CV death and all-cause death were negatively correlated with increasing serum bilirubin quintiles and actual bilirubin values. Serum bilirubin was negatively associated with incident cardiovascular death (hazard ratio: 0.26, 95% CI, 0.11–0.61, p = .01) and all-cause death (hazard ratio: 0.30, 95% CI, 0.17–0.51, p ≤.001). The addition of bilirubin for cardiovascular death increased the C-statistic from 0.713 (95% CI, 0.664–0.762) to 0.729 (95% CI, 0.681–0.776) (P = .008) and showed an integrated discrimination improvement (IDI) of 0.012 (P < .0171) with 8.57% improvement in net reclassification analysis (P = .0224). These results suggest additional predictive value is possible via total bilirubin levels for future CV deaths in diabetic patients. In terms of all-death, the addition of bilirubin significantly increased the C-statistic (from 0.769 to 0.78, P = .0064)—a 3.52% net reclassification improvement (P = .0307). It did not improve the IDI (p = .1505). ConclusionsHigher serum concentrations of bilirubin are associated with a decreased risk of developing CV and all-cause death in diabetic patients. Bilirubin improved the risk prediction of cardiovascular death but provided only a slightly better prediction of all-cause death than conventional risk factors.

Imaging to Stratify Coronary Artery Disease Risk in Asymptomatic Patients with Diabetes.

Coronary artery disease (CAD) is the leading cause of morbidity and mortality in patients with diabetes mellitus. Patients with diabetes have a higher prevalence of CAD and a larger magnitude of ischemia, and they are more likely to have silent myocardial ischemia and myocardial infarction. However, recent large cohort studies demonstrate that diabetic patients are not a homogenous group with similar high risk for cardiac events. In fact, more than 30% of asymptomatic diabetic patients do not have evidence of coronary atherosclerosis and have a very low annual cardiac event rate. Accordingly, there has been a recent paradigm shift as to whether the detection of subclinical coronary atherosclerosis through imaging can best guide therapeutic decision making. This review discusses the role of various cardiac imaging techniques for stratifying cardiovascular risk and optimizing therapy in asymptomatic diabetic patients.

P3187Meta-analysis of coronary CT angiography for risk stratification in asymptomatic diabetic patients

P3187Meta-analysis of coronary CT angiography for risk stratification in asymptomatic diabetic patients

1426Meta-analysis of SPECT-MPI for risk stratification in asymptomatic diabetic patients

1426Meta-analysis of SPECT-MPI for risk stratification in asymptomatic diabetic patients

Clinical Profile of Diabetic Patients with Liver Dysfunction

The spectrum of clinical disease in fatty liver with steatohepatitis varies from the asymptomatic elevation of liver enzymes to severe liver disease with fibrosis and nodular regeneration. Patients with nonalcoholic steatohepatitis can develop progressive liver disease and complications to the point that they may need liver transplantation.Nonalcoholic steatohepatitis should be considered as a cause for chronically elevated liver enzymes in asymptomatic diabetic patients particularly if they are obese and have hyperlipidemia.This study was carried out among 100 diabetic patients diagnosed to be with hepatic dysfunction attending tertiary care hospital during the study period. Maximum number of patients had diabetic nephropathy (17%), followed by diabetic retinopathy (15%), peripheral neuropathy (11%) and peripheral vascular disease (4%). Neuropathy, Nephropathy, PVD and Retinopathy were present in patients who had diabetes for more than 10 years.

Non-invasive screening for coronary artery disease in asymptomatic diabetic patients: a systematic review and meta-analysis of randomised controlled trials.

It is unclear whether non-invasive screening of asymptomatic diabetic patients for coronary artery disease (CAD) may improve cardiac outcomes. Thus, we performed a systematic literature review and meta-analysis of randomised controlled trials (RCT's) on this topic. We searched appropriate RCT's in five online databases (PubMed/MEDLINE, Cochrane Library, Embase, Scopus, and Web of Science) from January 2000 to November 2017 and in 41 recent reviews. Two investigators independently extracted and assessed study data using standardised forms. Additional unpublished data were obtained from trial authors. The primary endpoint 'any cardiac event' was a composite of cardiac death, non-fatal myocardial infarction (MI), unstable angina (UA), or heart failure (HF) hospitalisation. We performed a meta-analysis of relative risks (RRs) with 95% confidence intervals (CI) using the Mantel-Haenszel method. We included five RCT's with 3299 patients, of which 189 (5.7%) experienced any cardiac event on follow-up (weighted mean 4.1 years). Non-invasive CAD screening significantly reduced any cardiac event by 27% [RR 0.73 (95% CI 0.55-0.97), P = 0.028, number needed to screen 56]. This result was driven by important, albeit non-significant decreases in non-fatal MI [RR 0.65 (95% CI 0.41-1.02), P = 0.062] and HF hospitalisation [RR 0.61 (95% CI 0.33-1.10), P = 0.100]. Non-invasive CAD screening did not significantly affect cardiac death [RR 0.92 (95% CI 0.53-1.60), P = 0.77] and UA [RR 0.73 (95% CI 0.41-1.31), P = 0.29]. Compared with the standard care, non-invasive CAD screening reduced cardiac events by 27% in asymptomatic diabetic patients, largely through reductions in non-fatal MIs, and HF hospitalisations. The present results justify larger, appropriately powered trials to potentially revisit current recommendations.

Diabetes and Subclinical Coronary Atherosclerosis.

It is well known that diabetic patients have a high risk of cardiovascular events, and although there has been a tremendous effort to reduce these cardiovascular risks, the incidence of cardiovascular morbidity and mortality in diabetic patients remains high. Therefore, the early detection of coronary artery disease (CAD) is necessary in those diabetic patients who are at risk of cardiovascular events. Significant medical and radiological advancements, including coronary computed tomography angiography (CCTA), mean that it is now possible to investigate the characteristics of plaques, instead of solely evaluating the calcium level of the coronary artery. Recently, several studies reported that the prevalence of subclinical coronary atherosclerosis (SCA) is higher than expected, and this could impact on CAD progression in asymptomatic diabetic patients. In addition, several reports suggest the potential benefit of using CCTA for screening for SCA in asymptomatic diabetic patients, which might dramatically decrease the incidence of cardiovascular events. For these reasons, the medical interest in SCA in diabetic patients is increasing. In this article, we sought to review the results of studies on CAD in asymptomatic diabetic patients and discuss the clinical significance and possibility of using CCTA to screen for SCA.

Nerve conduction study in neurologically asymptomatic diabetic patients and correlation with glycosylated hemoglobin and duration of diabetes

Background: Diabetes-induced neuropathy is one of the most challenging complications of diabetes mellitus (DM). Large number of patients has subclinical neuropathy at the time of detection of diabetes. Nerve conduction studies (NCS) remain the most reliable, accurate, and sensitive measure of peripheral nerve function. The study of F waves is particularly useful for the diagnosis of peripheral neuropathy. Aims and Objectives: The present study was conducted to study various nerve conduction parameters in neurologically asymptomatic diabetic patients with an attempt to evaluate their value in the early detection of subclinical diabetic neuropathy and to find out if any correlation exists. Materials and Methods: This case–control study was carried out on 44 neurologically asymptomatic established patients of Type II DM of both sexes, aged 40–60 years attending the medicine outpatient department (OPD). NCS parameters of various nerves were studied. Blood sugar and glycosylated hemoglobin (HbA1c) were determined. Results: A longer latency, smaller amplitude and slower conduction velocity were found in all the nerves. Persistence was found to be lower and F-wave minimum latency prolonged amongst the cases. Sensory and motor NCS were found to be inferior in those with higher HbA1c. Latency, amplitude, and Nerve conduction velocity (NCV) of sural nerve showed deterioration with the duration of diabetes. All parameters of median, ulnar and common peroneal nerves showed deterioration with the duration of diabetes with the exception of NCV in common peroneal nerve and persistence in median nerve. Conclusions: NCS parameters are valuable for identification and future prediction of diabetic peripheral neuropath.

Circulating miR-19b and miR-181b are potential biomarkers for diabetic cardiomyopathy

Diabetic cardiomyopathy is characterized by metabolic changes in the myocardium that promote a slow and silent dysfunction of muscle fibers, leading to myocardium remodelling and heart failure, independently of the presence of coronary artery diseases or hypertension. At present, no imaging methods allow an early diagnosis of this disease. Circulating miRNAs in plasma have been proposed as biomarkers in the prognosis of several cardiac diseases. This study aimed to determine whether circulating miRNAs could be potential biomarkers of diabetic cardiomyopathy. Mice that were fed with a high fat diet for 16 months, showed metabolic syndrome manifestations, cardiac hypertrophy (without hypertension) and a progressive cardiac function decline. At 16 months, when maximal degree of cardiac dysfunction was observed, 15 miRNAs from a miRNA microarray screening in myocardium were selected. Then, selected miRNAs expression in myocardium (at 4 and 16 months) and plasma (at 4, 12 and 16 months) were measured by RT-qPCR. Circulating miR-19b-3p and miR-181b-5p levels were associated with myocardium levels during the development of diabetic cardiomyopathy (in terms of cardiac dysfunction), suggesting that these miRNAs could be suitable biomarkers of this disease in asymptomatic diabetic patients.

The importance of subclinical left ventricular dysfunction and blood pressure pattern in asymptomatic type-2 diabetic patients: the diagnostic and prognostic significance of Tissue Doppler parameters, left ventricular global longitudinal strain, and nighttime blood pressure during sleep

The primary aims of this study have been to explore the diagnostic and prognostic significance of Tissue Doppler parameters (TDI), global longitudinal strain (GLS), and blood pressure (BP) pattern in normotensive diabetic patients. MethodsThe study consisted of 121 diabetic patients and 41 healthy subjects. Conventional and TDI echocardiography were performed on all patients, including E/Em (ratio of diastolic velocities). GLS was derived from two-dimensional speckle-tracking. Ambulatory BP monitoring (ABPM) was obtained over 24h.Over the three year follow up, the end points were cardiac events (myocardial infarction, coronary revascularization procedures, new-onset angina, heart failure). ResultsGLS was found to be significantly lower (‐17.5±2.1vs-24.4±2.4; p<0.001), while E/Em was significantly higher (10.3±2.24vs7.4±1.8; p<0.001) in diabetic patients.A non-dipping pattern of BP was observed in 38 diabetic patients (31.4%); 14 diabetic patients had an increase in their nocturnal BP.Significant predictors of an adverse cardiac event: a reduction of GLS value (‐17%,p=0.05) increase in E/Em (>15, p=0.002) and systolic BP during nocturnal sleep (>119mmHg,p=0.020). ConclusionEarly detection of nocturnal hypertension and subclinical LV dysfunction by TDI and 2D spackle tracking are of significant clinical and prognostic importance.

Asymptomatic Urinary Tract Infection among Diabetic Patients Admitted at a Tertiary Care Hospital of Karachi

Objective: To determine frequency of urinary tract infection among asymptomatic diabetics, the etiological agents, antibiotic sensitivity and the pattern of antibiotic resistance to that organism. Methodology: This cross-sectional study was conducted at Taj Medical Complex, Hamdard University Hospital, and Karachi. A total of 395 patients with Diabetes Mellitus were enrolled in our study. All data were transformed in a structured Performa. All lab analysis plus Urine C/S were done with written consent from the patients. Data was maintained and analyzed on SPSS version 20. Results: Among the 395 included patients, 44 % (174) were females and 56 % (221) were males. 362 were taking oral hypoglycemic agents (OHA), 9 were under insulin and 24 were taking both insulin and OHA. The mean HbA1c was 8.08 ± 1.29. Out of 395 samples of urine C/S of asymptomatic diabetic patients, 242 samples showed growth of organisms more than 105 CFU (colony forming units). The most common organism in 160 (66.11%) cases was E.coli. The other organisms isolated were klebsiella in 37 (15.28%) cases, staph aureus in 30 (12.4%), proteus in 7 (2.3%), enterococcus in 8 (3.3%) case. UTI was found more common in those patients who were taking oral hypoglycemic agents as compared to those who were taking insulin. E-coli- was sensitive to ciprofloxacin in 88.75%, ceftriaxone in 67.9% and imipenum in 100%. Klebsiella was 100% sensitive to ciprofloxacin. It was also 100% sensitive to imipenum. Staph aureus was sensitive to ciprofloxacin in 70%cases and 77% sensitive to ampicillin. E.coli was resistant to ampicillin, cefixime and gentamycin. Klebsiella was resistant to ceftriaxone and pimpedic acid. Staph aureus was resistant to co-trimoxazole. Proteus was resistant to imipenum in 100% cases and enterococci were resistant to amikacin in 100% cases. Conclusion: The study concluded that the prevalence of UTI is higher in females as compared to males in asymptomatic diabetic patients. E.coli was the foremost etiological agent of UTI. It was also observed that the diseases incidence increases with increasing age and vice versa. Because of the frequency and severity of UTI in diabetes, prompt diagnosis and early treatment is compulsory to prevent consequent complications.

Predictors and prognostic impact of silent coronary artery disease in asymptomatic high-risk patients with diabetes mellitus

AimsEvaluation of predictors of silent coronary artery disease (SCAD) in high-risk asymptomatic diabetic patients and to evaluate their two-year outcome. Methods and resultsFour hundred diabetic patients without prior CAD but at high CAD risk underwent myocardial perfusion scintigraphy (MPS) in this prospective multicentre outcome trial. MPS were abnormal in 22% of patients. Male sex (OR 2.223, 1.152–4.290; p=0.017), diabetes duration (OR 1.049,1.015–1.085; p=0·005), peripheral artery disease (OR 2.134, 1·150–3.961; p=0.016), smoking (OR 2.064, 1.109–3.839; p=0·022), systolic blood pressure (OR 1.014, 1.00–1.03, p=0·056), brain natriuretic peptide (OR 1.002, 1.001–1.004, p=0·005) independently predicted an abnormal MPS: if <2 and >3 predictors were present, 3.2% and 47% patients had an abnormal MPS, respectively (p<0·001). Two-year major adverse cardiac event rates increased from 2·9% to 14·6%, cardiac death rates from 0·6% to 4·1% in patients with summed stress scores ≤10 and >10%, respectively (each p<0.045). ConclusionsMale sex, diabetes duration, peripheral artery disease, smoking, elevated systolic blood pressure and increased brain-natriuretic peptides independently predicted SCAD. In presence of >3 predictors, almost 50% of patients had an abnormal MPS. They may benefit from screening by MPS since the extent of the MPS abnormality discriminated clearly between a favourable compared to a bad 2-year outcome. However, even highest risk patients without objective evidence of CAD had a benign prognosis without need for specific evaluation or therapy.Trial Registration Number: ISRCTN87953632.

Prognostic Usefulness of Cardiac Stress Test Modalities in Patients With Type 2 Diabetes Mellitus Who Underwent Myocardial Perfusion Scintigraphy (from the Basel Asymptomatic High-Risk Diabetics' Outcome Trial)

Our study aimed to assess predictors of the stress test technique used and to evaluate the impact of exercise level achieved on risk stratification in patients with asymptomatic type 2 diabetes without a previous coronary artery disease. Little is known whether co-morbidities of these patients predict the stress technique and whether physical performance provides risk stratification: 400 patients underwent clinical evaluation and myocardial perfusion scintigraphy (MPS) using physical or pharmacological stress. Physical patients were divided into 2 groups: achieving <6 and ≥6 METs, respectively. The mean follow-up time was 2 years. Major cardiac events (MACEs) included myocardial infarction and/or cardiac death. Independent predictors of pharmacological stress were a body mass index of >30 kg/m2 (hazard ratio 1.076, 95% confidence interval 1.027 to 1.127, p = 0.002) and a peripheral arterial disease (hazard ratio 2.888, 95% confidence interval 1.446 to 5.769, p = 0.003). Pharmacological patients had more MACE than physical patients (3.2% vs 1.0%, p = 0.03). Patients achieving <6 METs had a similar MACE rate as pharmacological patients (3.0% vs 3.2%, p = not significant) and more MACE than patients achieving ≥6 METs (3.0% vs 0.4%, p = 0.01). In patients achieving <6 METs and in pharmacological patients, MPS added an incremental prognostic value to pretest information (p values for global chi-square 0.012 and 0.04, respectively). In high-risk asymptomatic diabetic patients, co-morbidities were predictive of the stress technique used. Pharmacological patients had more MACE, similar to those unable to achieve 6 METs. MPS provided an incremental prognostic value in pharmacological patients and in patients with <6METs. In contrast, patients who were able to achieve ≥6 METs were at low risk and do not need further risk stratification.