Cardiac Events In Type Research Articles

Rhodiola pre-conditioning reduces exhaustive exercise-induced myocardial injury of insulin resistant mice

Myocardial injury reduction and recovery under acute cardiac stress are adversely impacted by insulin resistance (IR). We previously demonstrated that Rhodiola improved cardiac anti-stress capacity in mice. Thus, this study focuses on the preventive efficacy of Rhodiola on exhaustive exercise (EE)-induced myocardial injury of IR mice. An 8-week high-fat diet (HFD) model of IR mice was established. Rhodiola was administrated by garaging. After the 8-week intervention, half of the mice performed EE to simulate acute cardiac stress, and determine myocardial injury; The remaining mice were sacrificed following fasting to assess metabolic disorder. We found myocardial injury induced by EE in IR mice was worse and was alleviated by Rhodiola pre-conditioning. Further, the nuclear factor erythroid 2-related factor 2 (Nrf2)-related antioxidant system was impaired by HFD, while mitochondrial dynamic fusion and fission were activated by HFD as a physiological protective compensation. The Rhodiola administration rescued Nrf2 impairment and further facilitated mitochondrial fusion and fission. All these results indicate that Rhodiola is a potential treatment for the prevention of cardiac events in type 2 diabetes mellitus and metabolic syndrome patients, and the Nrf2-related antioxidant activity and mitochondrial dynamics are the proposed mechanisms.

Role of Ertugliflozin in the Management of Diabetes Mellitus.

The novel oral sodium-glucose cotransporter-2 (SGLT2) inhibitor Ertugliflozin (SteglatroTM) is introduced as a monotherapy or in conjunction with another antidiabetic drug regimen for the treatment of type 2 diabetes mellitus (T2DM).Additional safe and efficient treatment options for patients and physicians are of utmost importance as the incidence of T2DM rises. As a standalone therapy or an adjunctive treatment, ertugliflozin seems to be a reliable and safe option.This narrative review seeks to report and analyze ertugliflozin's effectiveness, safety, cardiovascular (CV), and renal outcomes in T2DM. Various combinations of drugs and drug classes have been tried to reduce mortality and comorbidities associated with the use of antidiabetic agents, especially cardiogenic events and renal diseases. With the administration of hypoglycemic drugs like ertugliflozin and the regulation of blood sugar levels, the incidence of therapy-induced hypertension, obesity, and dose-related hypoglycemia has been reduced to a significant extent. Additionally, ertugliflozin prevents hypertension caused by prolonged antidiabetic drug intake, which is advantageous for lowering the chances of end-stage cardiac events in type 2 diabetic patients. As far as the renal safety profile of ertugliflozin is concerned, it has been associated with the maintenance of eGFR (estimated glomerular filtration rate) and a decreased UACR (urine albumin-to-creatinine ratio) in patients with T2DM and coronary artery disease, which reduces the incidence of renal adverse effects due to long-term medication. As a result of common pathophysiological mechanisms, SGLT2 inhibitors represent a feasible therapeutic option and are advantageous for patients with type 1 and type 2 DM in terms of cardiovascular and renal outcomes.

ECG descriptors of ventricular repolarization are associated with cardiac events in a gene-specific manner in long QT syndrome patients

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Assistance Publiques Hôpitaux de Paris (APHP) Background Congenital long QT syndrome (LQTS) is still associated with syncope and a risk of sudden cardiac death despite the dramatic reduction in mortality associated with beta-blocker therapy. Current risk stratification tools are imperfect. Objective To assess the contribution of automated scalar ECG descriptors of ventricular repolarization for arrrhythmic risk stratification in genotyped LQTS patients. Methods Patients with genotyped type 1, 2 or 3 LQTS with at least 1 digital ECG recording have been included in the study. History at diagnosis, and follow-up data were collected. Cardiac events included syncope, aborted cardiac arrest, appropriate implantable cardioverter-defibrillator therapy in VF zone, and sudden death. ECG were analyzed using the BRAVO algorithm embedded in the CalECG software, version 4.1.0. QT interval duration was manually checked but ECG descriptors of Ventricular Repolarization were fully automatic. Multivariate cox regression analysis were performed to identify parameters associated with cardiac events. Results 467 patients (58% female, median age at diagnosis=25, LQT1,2,3 54%, 39%, 7%) were followed-up during 15.2±9.2 years. Rate of cardiac event was 1.2/100 patients-year before diagnosis and 0.9/100 patients-year during follow-up. QTc duration was associated with the occurrence of cardiac events in the whole study population (HR=1.01 95%CI 1.0-1.01, p=0.03). Ventricular repolarization parameters associated with cardiac events were different according to LQTS type. Cardiac events were associated with increased time to accumulate 50% of T-wave energy (HR=1.53 95%CI 1.04-2.26, p=0.03) in LQT1 but with a decrease in T-wave slopes (ascending slope HR=0.63 95%CI 0.17-0.75, p<0.01) in type 2 LQTS patients. QTc duration was not independently associated with cardiac events in genotype specific multivariate models. Conclusions T-wave morphology parameters are associated with cardiac events in a gene-specific manner. Change in T-wave symmetry and T-wave flattening are associated with cardiac events in type 1 and type 2 LQTS respectively. The descriptors of ventricular repolarization are promising parameters or risk stratification beyond QTc duration in LQTS patients.

Assessment of physical function and health related quality of life according to the likelihood of adverse cardiac events in type 2 diabetic women

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Diabetes mellitus is a risk factor for cardiovascular disease. In women, one of the strongest and most consistent estimators of cardiac prognosis is functional capacity which is an important component affecting the predictive value of exercise testing. The Duke Activity Status Index (DASI) is a questionnaire and it correlates with a woman’s capabilities to perform adequate levels of exercise stress testing and predicts prognosis to a similar degre. The every unit increase in the DASI MET subsets (4.8-7-4, 7.5-9.9 and >9.9 METs) related to Bruce protocol, were associated with a 25% decrease in adverse cardiac events. Purpose To appreciate the physical function and health related quality of life according to the likelihood of adverse cardiac events using estimeted function capasity in type 2 diabetic women Methods Forty nine type 2 diabetic women (mean age: 61.48 ± 8.42 years) completed the DASI questionnaire for the functional capacity and SF-36 for health related quality of life. They also underwent two minute walk test, Up and Go test and one leg standing test. The women were divided into two groups according to functional capacity by their estimated MET capacity at < 7.5 (group 1 who had higher risk for adverse cardiac events) and ≥7.5 (group 2, who had lower adverse cardiac events risk) using DASI. Results The age, BMI, diabetes duration, HgA1c and SF-36 mental health weren’t different between the groups (p>.05). The education duration (p=.031), comorbidity number ((p=.035), the scores of two minute walk test (p=.000), Up and Go test (p=.000), one leg standing test (p=.001) and vitality (p=.002), physical functioning (p=.000), bodily pain (p=.040), physical role functioning (p=.003), emotional role functioning (p=.040) domains of SF-36 were greater in Group 2. Conclusions In the type 2 diabetic womens who had higher risk for adverse cardiac events, physical function was lower and quality of life was worse than those in the womens who had lower adverse cardiac events risk. The physical activity as a contributing factor to reduce the likelihood of adverse cardiac events and to increase the health related quality of life, should be improved.

Medium-term prognostic value of angio-TC in type 2 diabetic patients without known cardiopathy

Abstract Funding Acknowledgements Type of funding sources: None. Introdution The use of coronary angiography by cardiac CT for the active search for coronary disease in asymptomatic diabetic patients is not generally indicated. On the other hand, in the case of high-risk patients with a high calcium score, there are results that do show a potential benefit of expanding the study with CT coronary angiography. Purpose The aim was to determine the medium-term prognostic value of computed tomography non-invasive coronary angiography (CT angiography) to predict major cardiac events in type 2 diabetic patients (p) without previous cardiac symptoms Methods Observational and prospective study in diabetic patients without symptoms suggestive of coronary heart disease (CHD), derived from performing a CT in the previous 5 years, for different reasons, not related to acute coronary syndrome. The presence of CHD was analyzed, as well as the incidence for cardiac events during follow-up. Results 402 diabetic patients, mean evolution time of the disease: 6.8 +/- 2.1 years, mean Hb1Ac 8.1 +/- 0.7%. 60% of patients were male. Regarding other cardiovascular risk factors: 66.3% were hypertensive. 58.8% dyslipidemic. 26.3% obese. 27.5% smokers. 32.5% ex-smokers. 36.3% had a family history of CHD. Most frequent indication for CT: CHD screening, with previous inconclusive tests (26.3%), followed by pre-surgery evaluation (25%). Agatston Score 278.3 ± 235.8, Agatston Score> 400 132 (32.8%), significant CHD 174 (43.2%), Vulnerable plaques 84 (20.9%) The average follow-up was 5 years (+/- 1.3); 90 p (22.3%) suffered cardiac events (63 cardiac deaths, 27 non-fatal myocardial infarction). Best correlation with events was observed with the presence of significant coronary disease (ostruction> 50%) compared to the Agatston score and the presence of vulnerable plaques (adjusted c-index of 0.59 versus univariate c-index of 0.42, respectively) The annual event rate for patients with normal coronary arteries was 1.8%, which translated into a 5-year event-free survival period. The highest annual event rate of 22.3% was detected in patients with obstructive 3-vessel CAD Conclusions Non-invasive CT angiography allows, after quantifying plaque severity in diabetic patients, to reclassify patients at high / very high risk Diabetic patients with normal coronary arteries on CT angiography had a 5-year survival period free of major cardiac events.

The First Harmonic of Radial Pulse as an Early Predictor of Silent Coronary Artery Disease and Adverse Cardiac Events in Type 2 Diabetic Patients.

Background It has been reported that harmonics of radial pulse is related to coronary artery disease (CAD) in patients with type 2 diabetes mellitus (T2DM). It is still unclear whether or not the first harmonics of the radial pulse spectrum is an early independent predictor of silent coronary artery disease (SCAD) and adverse cardiac events (ACE). Objectives To measure the risk of SCAD in patients with T2DM and also to survey whether or not an increment of the first harmonic (C1) of the radial pulse increases ACE. Methods 1968 asymptomatic individuals with T2DM underwent radial pulse wave measurement. First harmonic of the radial pressure wave, C1, was calculated. Next, the new occurrence of ACE and the new symptoms and signs of coronary artery disease were recorded. The follow-up period lasted for 14.7 ± 3.5 months. Results Out of 1968 asymptomatic individuals with T2DM, ACE was detected in 239 (12%) of them during the follow-up period. The logrank test demonstrated that the cumulative incidence of ACE in patients with C1 above 0.96 was greater than that in those patients with C1 below 0.89 (P < 0.01). By comparing the data of patients with C1 smaller than the first quartile and the patients with C1 greater than the third quartile, the hazard ratios were listed as follows: ACE (hazard ratio, 2.29; 95% CI, 1.55–3.37), heart failure (hazard ratio, 2.22; 95% CI, 1.21–4.09), myocardial infarction (hazard ratio, 2.44; 95% CI, 1.51–3.93), left ventricular dysfunction (Hazard ratio, 2.01; 95% CI, 0.86–4.70), and new symptoms and signs for coronary artery disease (hazard ratio, 2.03; 95% CI, 1.45–2.84). As C1 increased, the risk for composite ACE (P < 0.001 for trend) and for coronary disease (P < 0.001 for trend) also increased. The hazard ratio and trend for cardiovascular-cause mortality were not significant. Conclusions This study showed that C1 of the radial pulse wave is correlated with cardiovascular events. Survival analysis showed that C1 value is an independent predictor of ACE and SCAD in asymptomatic patients with T2DM. Thus, screening for the first harmonic of the radial pulse may improve the risk stratification of cardiac events and SCAD in asymptomatic patients although they had no history of coronary artery disease or angina-related symptom.

Atherosclerosis Is Associated with Neutrophil Lymphocyte Ratio As An Inflammatory Marker in Type 2 Diabetes Mellitus Patients with Coronary Artery Disease

Background: Increased neutrophil lymphocyte ratio is associated with major adverse outcomes of cardiac events in type 2 diabetes mellitus (DM) patients.Objective: To assess the NLR as an inflammatory marker in atherosclerosis in type 2 DM patients with coronary artery disease (CAD).Methods: This case control study was conducted in the Department of Clinical Pathology in collaboration with Department of Cardiology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, from March 2014 to February 2015. Total 134 patients were enrolled in this study who were waiting for coronary angiography in the Department of Cardiology, BSMMU; 84 cases were considered as Group I (DM with CAD) and 50 controls were Group II (DM without CAD). A 2 ml of blood was collected in EDTA tube from the patients prior to coronary angiogram for complete blood count (CBC) were measured by haematology autoanalyzer, rechecked manually and NLR was calculated in the Department of Clinical Pathology, BSMMU. Coronary artery disease with 50% coronary artery stenosis and more critical lesion that were diagnosed by coronary angiography were included in this study as cases. Coronary artery disease with less than 50% coronary artery stenosis that was diagnosed by coronary angiography was included in this study as control.Results: NLR was higher in CAD positive group compared to group without CAD negative in type 2 DM patients (2.76 (±0.74) vs. 1.56 (±0.15), p&lt;0.001).Conclusion: With the help of neutrophil lymphocyte ratio we can take preventive measure and precaution to reduce the progression of atherosclerosis in type 2 diabetic patients with coronary artery disease.J Dhaka Medical College, Vol. 24, No.1, April, 2015, Page 24-29

Simvastatin–ezetimibe combination therapy is associated with a lower rate of major adverse cardiac events in type 2 diabetics than high potency statins alone: A population-based dynamic cohort study

BackgroundRecent trials have shown a reduction in the risk of major adverse cardiac events (MACE) with simvastatin–ezetimibe therapy in patients with acute coronary syndrome. The potential benefits of simvastatin–ezetimibe for patients at a lower risk of MACE are unclear. This study aimed to investigate the differences of MACE risk between patients with type 2 diabetes mellitus (DM) using simvastatin–ezetimibe or high potency statins. MethodsThis population-based dynamic cohort study used data from the Taiwan National Health Insurance Database. The study subjects were patients with type 2 DM, aged between 40 and 75years. The simvastatin–ezetimibe group took simvastatin–ezetimibe only, and the statin group took atorvastatin or rosuvastatin but not simvastatin or ezetimibe. The two groups were matched for age, gender, medication date, DM diagnosis date, hypertension, and cardiovascular complications. The outcome variable was new-onset MACE. Univariate and multivariate survival analyses were performed. ResultsA total of 20,485 patients (53% male; 4099 in the simvastatin–ezetimibe group and 16,396 in the statin group) were included, with a mean age of 59.1years. In a total of 37,388person-years, 1100 patients developed new-onset MACE. The annual incidence rate of new-onset MACE was lower in the simvastatin–ezetimibe group (2.61%) than that in the statin group (3.02%) (p=0.0476). After Cox regression analysis, simvastatin–ezetimibe use was independently associated with a lower risk of MACE (HR, 0.77; 95% confidence interval 0.66–0.90). ConclusionsCompared to high potency statins alone, simvastatin–ezetimibe therapy was associated with a lower incidence of MACE in patients with type 2 DM.

Mutations in Cytoplasmic Loops of the KCNQ1 Channel and the Risk of Life-Threatening Events

Background— β-Adrenergic stimulation is the main trigger for cardiac events in type 1 long-QT syndrome (LQT1). We evaluated a possible association between ion channel response to β-adrenergic stimulation and clinical response to β-blocker therapy according to mutation location. Methods and Results— The study sample comprised 860 patients with genetically confirmed mutations in the KCNQ1 channel. Patients were categorized into carriers of missense mutations located in the cytoplasmic loops (C loops), membrane-spanning domain, C/N terminus, and nonmissense mutations. There were 27 aborted cardiac arrest and 78 sudden cardiac death events from birth through 40 years of age. After multivariable adjustment for clinical factors, the presence of C-loop mutations was associated with the highest risk for aborted cardiac arrest or sudden cardiac death (hazard ratio versus nonmissense mutations=2.75; 95% confidence interval, 1.29–5.86; P =0.009). β-Blocker therapy was associated with a significantly greater reduction in the risk of aborted cardiac arrest or sudden cardiac death among patients with C-loop mutations than among all other patients (hazard ratio=0.12; 95% confidence interval, 0.02–0.73; P =0.02; and hazard ratio=0.82; 95% confidence interval, 0.31–2.13; P =0.68, respectively; P for interaction=0.04). Cellular expression studies showed that membrane spanning and C-loop mutations produced a similar decrease in current, but only C-loop mutations showed a pronounced reduction in channel activation in response to β-adrenergic stimulation. Conclusions— Patients with C-loop missense mutations in the KCNQ1 channel exhibit a high risk for life-threatening events and derive a pronounced benefit from treatment with β-blockers. Reduced channel activation after sympathetic activation can explain the increased clinical risk and response to therapy in patients with C-loop mutations.

Combined Assessment of Myocardial Perfusion and Function by ECG-Gated Myocardial Perfusion Single-Photon Emission Computed Tomography for the Prediction of Future Cardiac Events in Patients With Type 2 Diabetes Mellitus

The mid-term prognostic significance of ECG-gated single-photon emission computed tomography (SPECT) remains unclear in Japanese patients with type 2 diabetes mellitus (DM). In the present study rates of future cardiac events (nonfatal acute myocardial infarction (AMI), cardiac death (CD) and severe heart failure (HF) requiring hospitalization) were compared in patients with and without DM. 1,810 patients (563 DM and 1,247 non-DM) we followed for a mean of 26.3±15.5 months. Summed stress score (SSS), summed difference score (SDS), poststress ejection fraction (EF) and resting end-diastolic volume (EDV) were calculated. In total, 20 cases of AMI (9 in DM (1.59%) and 11 in non-DM (0.88%)), 20 of CD (7 in DM patients (1.24%) and 13 in non-DM (1.04%)) and 54 of severe HF (31 in DM (5.5%) and 23 in non-DM (1.84%)) occurred. Univariate Cox analysis showed that, in DM patients, predictors of total cardiac events were poststress EF (Wald 60.4; P<0.001), resting EDV (Wald 53.8; P<0.001), SSS (Wald 39.6; P<0.001), SDS (Wald 26.1; P<0.001), history of prior MI (Wald 4.32; P<0.05) and hemoglobin A(1c) value (Wald 4.30; P<0.05). Multivariate Cox analysis showed that poststress EF (Wald 9.85; P<0.01) and SDS (Wald 6.19; P<0.01) were independent predictors of total cardiac events. Combined assessment of perfusion and function by ECG-gated SPECT may predict future cardiac events in type 2 DM patients.

Heart rate-dependent variability of cardiac events in type 2 congenital long-QT syndrome

We aimed to examine the validity of heart rate (HR) at rest before β-blocker therapy as a risk factor influencing cardiac events (ventricular fibrillation, torsades de pointes, or syncope) in long QT type 2 (LQT2) patients. In 110 genetically confirmed LQT2 patients (45 probands), we examined the significance of variables [HR at rest, corrected QT (QTc), female gender, age of the first cardiac event, mutation site] as a risk factor for cardiac events. We also evaluated frequency of cardiac events in four groups classified by the combination of basal HR and QTc with cutoff values of 60 b.p.m. and 500 ms to estimate if these two electrocardiographic parameters in combination could be a good predictor of outcome (mean follow-up period: 50 ± 39 months). Logistic regression analysis revealed three predictors: HR < 60 b.p.m., QTc ≥ 500 ms, and female gender. When the study population was divided into four groups using the cutoff values of 60 b.p.m. for HR and 500 ms for QTc, the cumulative event-free survival by the Kaplan-Meier method was significantly higher in the group with HR ≥ 60 b.p.m. and QTc < 500 ms than in the group with HR < 60 b.p.m. and QTc < 500 ms or that with HR < 60 b.p.m. and QTc ≥ 500 m (P < 0.05). Irrespective of QTc interval, LQT2 patients with basal HR < 60 b.p.m. were at significantly higher risk. The basal HR of < 60 b.p.m. is a notable risk factor for the prediction of life-threatening arrhythmias in LQT2 patients.

Relationship between level of circulating modified LDL and the extent of coronary artery disease in type 2 diabetic patients

The impact of diabetes on health is due almost entirely to a series of complications that characterise the disease. It is associated with an increased incidence of macrovascular complications including coronary artery disease (CAD). The aim of the present study is to evaluate the possible relationship between the circulating levels of the modified derivatives of low-density lipoprotein (LDL) and the development of angiopathy in type 2 diabetic patients with CAD. The status of the antioxidant defences and the role of supplementation with antioxidant combinations are also studied in these patients. The study was conducted on three groups: group I (controls); group II (type 2 diabetic patients without complications – CAD[–]); and group III (including type 2 diabetic patients with stable CAD – CAD[+]). Patients in group III received adjunct treatment of antioxidant tablets for three months. The results of the present study clearly indicated that there was excessive exposure to oxidative stress in diabetic patients. The increase in free radicals was coupled with disturbance in free radical scavengers, particularly the glutathione system. The disturbance was more prominent in CAD(+) patients. The study has shown alteration in the lipid profile in diabetic groups, where the oxidised LDL (ox-LDL) levels were significantly higher than in control subjects. Diabetics with CAD had higher levels of ox-LDL than did patients without CAD. The intima/media thickness (IMT) of the carotid artery was within clinically accepted normal values if the ox-LDL level was below 100–110 u/L. Once the ox-LDL exceeded this range, IMT increased sharply with the increase in plasma ox-LDL. It seems that the level of ox-LDL should be kept below an upper limit of the 100–110 u/L range in order to avoid the serious atherosclerotic effects of this factor. The results demonstrate that plasma levels of ox-LDL correlate with the extent of coronary artery disease in type 2 diabetic patients and suggest that elevated levels of ox-LDL, can serve as an independent and significant predictor for future cardiac events in type 2 diabetic patients with CAD.

Value of diagnostic tools for myocardial ischemia used in routine clinical practice to predict cardiac events in patients with type 2 diabetes mellitus: a prospective study

To analyze tests used in routine clinical practice for the diagnosis of myocardial ischemia to predict the development of cardiac events in type 2 diabetic patients. The occurrence of cardiac events (new myocardial infarct, myocardial re-vascularization procedures, congestive heart failure, acute pulmonary edema, sudden death, and death after myocardial infarction or pulmonary edema) were prospectively assessed in a cohort of 135 type 2 diabetic patients after up to seven years of follow-up. At baseline, coronary artery disease was assessed by the WHO cardiovascular questionnaire, resting electrocardiogram, and stress myocardial scintigraphy. Forty-eight cardiac events were observed in 41 patients (10.5 events/100 patients-year). In a Cox's proportional-hazard model only the presence of symptoms of coronary artery disease on the WHO cardiovascular questionnaire alone (RR = 2.13, 95% CI 1.11-4.07, P= 0.022) or in combination with abnormalities on resting ECG (RR= 2.03, 95% CI 1.05-3.92, P= 0.034) or on myocardial scintigraphy (RR= 1.89, 95% CI 1.001-3.57, P= 0.050) predicted cardiac events, adjusted for fasting plasma glucose, mean blood pressure, body mass index, peripheral vascular disease and diabetic nephropathy. The WHO cardiovascular questionnaire, a simple tool for the diagnosis of coronary artery disease, is a significant predictor of cardiac events in type 2 diabetic patients.

Cardiac events in 735 type 2 diabetic patients who underwent screening for unknown asymptomatic coronary heart disease: 5-year follow-up report from the Milan Study on Atherosclerosis and Diabetes (MiSAD).

To report the cardiac events in type 2 diabetic outpatients screened for unknown asymptomatic coronary heart disease (CHD) and followed for 5 years. During 1993, 925 subjects aged 40-65 years underwent an exercise treadmill test (ETT). If it was abnormal, the subjects then underwent an exercise scintigraphy. Of the 925 subjects, 735 were followed for 5 years and cardiac events were recorded. At the entry of the study, 638 of the 735 followed subjects had normal ETT, 45 had abnormal ETT with normal scintigraphy, and 52 had abnormal ETT and abnormal scintigraphy. The 52 subjects with abnormal scintigraphy and ETT underwent a cardiological and diabetological follow-up; the subjects with just abnormal ETT had a diabetological follow-up only. During the follow-ups, 42 cardiac events occurred: 1 fatal myocardial infarction (MI), 20 nonfatal MIs, and 10 cases of angina in the 638 subjects with normal ETT; 1 fatal MI in the 45 subjects with normal scintigraphy; and 1 fatal MI and 9 cases of angina in the 52 subjects with abnormal scintigraphy. In these 52 subjects all cardiac events were significantly more frequent (chi(2) = 21.40, P < 0.0001) but the ratio of major (cardiac death and MI) to minor (angina) cardiac events was significantly lower (P = 0.002). Scintigraphy abnormality (hazard ratio 5.47; P < 0.001; 95% CI 2.43-12.29), diabetes duration (1.06; P = 0.021; 1.008-1.106), and diabetic retinopathy (2.371; P = 0.036; 1.059-5.307) were independent predictors of cardiac events on multivariate analysis. The low ratio of major to minor cardiac events in the positive scintigraphy group may suggest, although it does not prove, that the screening program followed by appropriate management was effective for the reduction of risk of major cardiac events.