Coronary Atherosclerosis In Asymptomatic Patients Research Articles

Screening for Atherosclerotic Cardiovascular Disease in Patients With Type 2 Diabetes Mellitus: Controversies and Guidelines.

If a disease state is highly prevalent and its consequences are severe, it may be appropriate to seek methods to identify it early to forestall its development and complications. Diabetes mellitus is a proven risk factor for the development of atherosclerosis, although its face and outcome are changing, as shown in contemporary clinical trials. In fact, decompensated heart failure seems to drive the hospitalization rate in patients with diabetes, and mortality from heart failure is reduced with modern hypoglycemic treatments. Nonetheless, atherosclerotic complications continue to be a major health concern in this segment of the population and cardiovascular imaging has been employed in an attempt to achieve a more accurate risk stratification. Although imaging for detection of obstructive coronary artery disease failed to reach such a goal, imaging for preclinical atherosclerosis may be more successful. In this review, we discuss the use of computed tomography and positron emission tomography to detect preclinical coronary atherosclerosis in asymptomatic patients with diabetes. Despite recent advances in the field, several questions remain to be answered as to the ultimate benefit of imaging for prevention in diabetes mellitus.

Volumes of coronary plaque disease in relation to body mass index, waist circumference, truncal fat mass and epicardial adipose tissue in patients with type 2 diabetes mellitus and controls.

Coronary atherosclerosis in patients with type 2 diabetes mellitus may be promoted by regional fat distribution. We investigated the association between anthropometric measures of obesity, truncal fat mass, epicardial adipose tissue and coronary atherosclerosis in asymptomatic patients and matched controls. We examined 44 patients and 59 controls [mean (standard deviation) age 64.4 ± 9.9 vs 61.8 ± 9.7, male 50% vs 47%, diabetes duration mean (standard deviation) 7.7 ± 1.5] with coronary computed tomography angiography. Coronary plaques were quantified as total, calcified, non-calcified and low-density non-calcified plaque volumes (mm3). Regional fat distribution was assessed by dual-energy X-ray absorptiometry, body mass index (kg/m2), waist circumference (cm) and epicardial fat volume (mm3). Endothelial function and systemic inflammation were evaluated by peripheral arterial tonometry (log transformed Reactive Hyperemia Index) and C-reactive protein (mg/L). Body mass index and waist circumference (p < 0.02) were associated with coronary plaque volumes. Body mass index was associated with low-density non-calcified plaque volume after adjustment for age, sex and diabetes status (p < 0.01). Truncal fat mass (p > 0.51), waist circumference (p > 0.06) and epicardial adipose tissue (p > 0.17) were not associated with coronary plaque volumes in adjusted analyses. Body mass index is associated with coronary plaque volumes in diabetic as well as non-diabetic individuals.

Increased high-risk coronary plaque burden is associated with arterial stiffness in patients with type 2 diabetes without clinical signs of coronary artery disease

Arterial stiffness and subclinical coronary atherosclerosis may yield valuable information on cardiovascular risk. We aimed to characterize coronary atherosclerosis in asymptomatic patients with type 2 diabetes and healthy controls and to investigate the association between baseline arterial stiffness and coronary plaque volumes after 5-year follow-up. Data from 45 patients and 61 matched controls were available for coronary plaque assessment. For analysis including carotid-femoral pulse wave velocity (PWV), 43 patients and 55 controls were available. At follow-up, mean (SD) age of participants was 63 ± 10 years, and mean diabetes duration (SD) in the patient group was 7.8 ± 1.4 years. Arterial stiffness (PWV) was assessed by tonometry at both visits. Total, calcified, noncalcified, low-density noncalcified coronary plaques volumes and other plaque characteristics were assessed by coronary computed tomography angiography at follow-up. Despite of similar or better blood pressure and plasma lipid control, patients had, compared with controls, a higher number of plaques with spotty calcifications (P < 0.01) and remodeling index more than 1.1 (P < 0.05), larger calcified plaque volumes [patients vs. 11 (0-65) vs. 3 (0-30) μl (P = 0.03)] and higher PWV [patients vs. controls at baseline: 9.1 ± 2.2 vs. 7.9 ± 1.4 m/s (P < 0.01), at follow-up: 9.3 ± 2.3 vs. 8.4 ± 1.8 m/s (P = 0.02)]. Baseline PWV was associated with volumes of all plaque types in crude analysis (P < 0.01) and with low-density noncalcified plaque volume in analysis adjusted for age, sex, diabetes and blood pressure (P = 0.01). Coronary plaques with unfavorable characteristics are more prevalent in well controlled asymptomatic patients with type 2 diabetes compared with healthy controls and independently associated with arterial stiffness.Clinical trials registration number: NCT02001532.

Low Prevalence of Subclinical Atherosclerosis in Asymptomatic Patients With Type 1 Diabetes in a European Mediterranean Population

To evaluate the presence of early carotid and coronary atherosclerosis in asymptomatic patients with type 1 diabetes with no history of ischemic heart disease. One hundred and fifty patients with type 1 diabetes (58% males; 38.6 ± 8.1 years, 20.4 ± 8.1 years of evolution; HbA1c 8.1 ± 2.3%; 52% nonsmokers; 26% retinopathy; 9% microalbuminuria) and 50 nondiabetic control subjects age and sex matched were studied. Carotid ultrasonography to determine common carotid artery intima-media thickness (c-IMT) and the presence of atheroma plaques and cardiac computed tomography for calcium analysis and quantification (coronary artery calcium score [CACS]) were performed. Most patients with type 1 diabetes and control subjects displayed a CACS of 0 (82 vs. 92%). Patients with type 1 diabetes with CACS ≥1 were older and had higher HbA1c (44.5 ± 5.1 vs. 36.7 ± 8.1 years [P < 0.001] and 8.5 ± 1.1 vs. 7.8 ± 1.0% [P < 0.003], respectively) and longer evolution of diabetes (25.4 ± 9.2 vs. 19.3 ± 7.4 years, P < 0.005) and mean c-IMT (0.67 ± 0.18 vs. 0.53 ± 0.11 mm, P < 0.001) compared with patients with CACS of 0. Smoking (P < 0.02), nephropathy (P < 0.05), retinopathy (P < 0.05), and male sex (P < 0.03) were significantly and positively associated with CACS ≥1. Mean c-IMT was significantly higher in patients with type 1 diabetes (0.55 ± 0.14 vs. 0.48 ± 0.14 mm, P < 0.01), and 11% of them presented atheroma plaques (8% of control subjects). Multivariant logistic regression analysis showed that c-IMT was related to CACS (β = 6.87, P < 0.001). A small percentage of patients with type 1 diabetes showed data suggestive of subclinical atherosclerosis. Universal screening of coronary disease in this population is not justified. Carotid ultrasonography may be useful for screening in the subset of patients with cardiovascular risk factors and long disease evolution.

New Strategy for Detection of Subclinical Coronary Atherosclerosis in Asymptomatic Patients With Type 2 Diabetes Based on Cardiac Multi-Detector Computed Tomography and Treadmill Test

The current screening strategy for subclinical coronary atherosclerosis in asymptomatic diabetic patients is not sufficient in real clinical practice. A new strategy was investigated that uses cardiac multi-detector computed tomography (MDCT) and a treadmill test (TMT). A total of 445 self-referred asymptomatic diabetic patients underwent cardiac MDCT. The treatment plan was determined according to the new strategy that uses MDCT and TMT. All patients underwent clinical follow-up and cardiac events were investigated. The incidence of subclinical atherosclerosis was 49.4%. The group without plaque underwent clinical follow-up without treatment and did not experience any cardiac events in 675.1 person-years of follow-up. Among patients with subclinical atherosclerosis without significant stenosis (n=136) who received medical treatment only, 11 patients experienced cardiac events over 326.4 person-years. The patients with significant stenosis (n=84) underwent TMT. Patients with positive TMT (n=14) underwent coronary angiograms and revascularization therapy was performed in all of them over 39.2 person-years. Patients with negative TMT (n=70) underwent medical treatment, and 27 of them experienced cardiac events. The incidence of cardiac death was 0% during 3 years of follow-up. The new strategy for detecting subclinical atherosclerosis on MDCT combined with TMT may be a useful method for minimizing the mortality rate from cardiovascular disease in asymptomatic diabetic patients.

Bone-related circulating proteins as early predictors of coronary atherosclerosis in asymptomatic patients with known coronary artery disease

Methods. 126 subjects with previously documented asymptomatic coronary artery disease (CAD) were enrolled in the study. CAD was determined with contrast multispiral CTangiography. Osteopontin (OPN) and osteoprotegerin (OPG) were measured with ELISA. Concentration of high sensitive C-reactive protein (hsCRP) was measured by nephelometric technique. Results. Analysis of the results showed that in a patient's cohort, the mean of circulating OPN value was 43.55 ng/mL (95% CI = 31.5 – 57.0 ng/mL). The mean value of circulating OPG was 3849.51 pg/mL (95% CI = 3282.23 4413.79 pg/mL). The independent predictors of coronary atherosclerosis determined with Agatston score index and %AS > 50% were OPN, OPG, T2DM, TC, and hs-CRP. The cutoff point for the OPG (AUC = 0.977), OPN (AUC = 0.851) and hs-CRP (AUC = 0.897) concentrations were 3229.8 pg / mL; 48.5 ng / mL and 5.6 mg / L respectively. In conclusions, we predisposed that circulating OPG in patients with asymptomatic atherosclerosis can be regarded as the best early marker of coronary artery calcification when compared with OPN, and hs-CRP.

Carotid doppler ultrasonography as a surrogate for coronary CT angiography to exclude subclinical coronary atherosclerosis in asymptomatic patients with a negative coronary calcium score

To evaluate the diagnostic accuracy of carotid Doppler ultrasonography (CDU) to predict the presence of subclinical coronary atherosclerosis in asymptomatic subjects with a zero coronary calcium score. Retrospective study of CDU and coronary CT angiography (CTA) findings in 118 asymptomatic subjects with a zero calcium score. CDU was considered abnormal when carotid intima-media thickness was >75 percentile or was ≥ 1 mm, or in presence of carotid plaque(s). We analyzed the diagnostic accuracy of CDU to predict the presence of non-calcified coronary plaque in comparison with coronary CTA. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of abnormal CDU to identify the presence of non-calcified coronary plaque on coronary CTA were 82.4% [(14/17); 95% confidence interval (CI), 56.6%-96.2%], 53.5% [(54/101); 95% CI, 43.3%-63.5%], 23.0% [(14/61); 95% CI, 13.1%-35.6%], and 94.7% [(54/57); 95% CI, 85.4%-98.9%], respectively. Although CDU has a low PPV for identifying the presence of non-calcified plaque on coronary CTA, its NPV is high to exclude subclinical coronary atherosclerosis in asymptomatic subjects with a zero calcium score.

Cardio-ankle vascular index reflects coronary atherosclerosis in patients with abnormal glucose metabolism: Assessment with 256 slice multi-detector computed tomography

ObjectiveThe association between arterial stiffness, as measured by the cardio-ankle vascular index (CAVI), and coronary atherosclerosis, using coronary artery computed tomography (CT), was investigated in the asymptomatic general population, with special interest in subjects with abnormal glucose metabolism. Patients and methodsA total of 158 normoglycemic subjects and 373 subjects with abnormal glucose metabolism were evaluated. CAVI was assessed in relation with coronary artery calcium score (CACS) and degree of stenosis detected by CT. ResultsThe association of CAVI with other clinical parameters was evaluated in patients with abnormal glucose metabolism. CAVI was higher, and CACS and the degree of coronary artery stenosis were both greater compared to the normal group. CAVI showed a significant correlation with CACS and the degree of stenosis (r=0.167, p=0.001; r=0.182, p<0.001, respectively). The cut-off level of CAVI from receiver operating characteristic (ROC) curve was ≥8.0 for predicting ≥50% coronary artery stenosis (area under the curve 0.713, sensitivity 69%, and specificity 61%). CAVI ≥8.0 was independently associated with significant coronary artery stenosis, even after adjusting for age, sex, and presence of hypertension and hypercholesterolemia (odds ratio 3.143, 95% confidence interval 1.004–9.842, p=0.049). ConclusionCAVI is an independent parameter which reflects coronary atherosclerosis in patients with abnormal glucose metabolism. CAVI can be a useful tool not only to assess arterial stiffness, but also to evaluate the risk for subclinical coronary atherosclerosis in asymptomatic patients.

Effect of Metabolic Syndrome on Coronary Artery Stenosis and Plaque Characteristics as Assessed with 64–Detector Row Cardiac CT

To investigate the prevalence and severity of subclinical coronary atherosclerosis and plaque characteristics in asymptomatic subjects according to the presence or absence of metabolic syndrome (MS) with multidetector computed tomography (CT). This study was approved and the requirement for informed patient consent was waived by the local institutional review board. Degree of coronary artery stenosis, multivessel involvement, and plaque characteristics, as well as coronary artery calcium score (CACS), were assessed with 64-detector row CT in 3000 age- and sex-matched asymptomatic individuals (mean age, 50.2 years ± 8.9 [standard deviation]; age range, 30-79 years). Anthropometric and metabolic profiles were also measured. Multivariate logistic regression analyses were performed to identify variables related to coronary atherosclerosis and plaque types. Subjects with MS had significant coronary artery stenosis (>50% stenosis), multivessel involvement, more positive remodeling, more atherosclerotic coronary segments, and higher CACS than subjects without MS (P < .01 for all). Mixed and noncalcified plaques were also more prominent in subjects with MS than in those without MS (14.2% ± 4.4 vs 7.6% ± 3.1 and 13.1% ± 4.3 vs 7.3% ± 2.8, respectively; P < .01 for both). After adjustment for confounding factors, MS was strongly associated with significant coronary artery stenosis, multivessel involvement, and mixed plaque. Multidetector CT is useful in the early diagnosis and evaluation of subclinical coronary atherosclerosis in asymptomatic patients with MS; however, future prospective studies are needed to address the clinical implications of these findings.

Arterial Stiffness Measured as Pulse Wave Velocity is Highly Correlated with Coronary Atherosclerosis in Asymptomatic Patients

Carotid-femoral pulse wave velocity is a well-known predictor of all-cause and cardiovascular mortality. Few studies have evaluated the relationship between brachial-ankle pulse wave velocity (ba-PWV) and coronary artery disease. We conducted this study to elucidate the relationship between arterial stiffness measured by ba-PWV and coronary atherosclerosis. An automatic waveform analyzer was used to measure the ba-PWV. Multidetector computed tomography coronary angiography was used to assess the coronary artery calcium (CAC) score and to detect coronary stenosis. A total of 654 patients, including 358 women and 296 men (mean age, 54.5 ± 9.4 years), were recruited during the period March 2005 to June 2008. One hundred and twenty-seven patients (19.4%) had at least one stenotic coronary vessel. Mean ba-PWV and mean CAC scores were significantly higher in the stenotic group than in the normal control (15.94 ± 3.07 m/s vs. 14.39 ± 0.98 m/s; 293.1 ± 435.9 vs. 29.8 ± 110.8, respectively; both p < 0.001). The adjusted OR for coronary stenosis increased as ba-PWV increased (p for trend = 0.0001). Using ba-PWV < 14.0 m/s as the reference group, we found that ba-PWV between 14.0-18.0 m/s and ba-PWV > 18.0 m/s were significantly associated with coronary stenosis (OR, 2.48; CI, 1.56-3.93 and OR, 3.16; CI, 1.68-5.95, respectively). The cutoff point at 15.64 m/s using the ROC curve showed a sensitivity of 64.5%, specificity of 65.6%, and an AUC of 0.662 in predicting coronary artery stenosis. Ba-PWV had an additional power for correlating coronary artery disease with the Framingham risk score. Ba-PWV correlated well with coronary atherosclerosis. Lifestyle modification is an efficacious therapeutic intervention for preventing the progression of arterial stiffness. This non-invasive technique can assist in the early detection of cardiovascular disease and should be included in community screening programs.

Assessment of Subclinical Coronary Atherosclerosis in Asymptomatic Patients With Type 2 Diabetes Mellitus With Single Photon Emission Computed Tomography and Coronary Computed Tomography Angiography

We evaluated the characteristics of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus (DM) using single photon emission computed tomography (SPECT) and coronary computed tomographic angiography (CCTA). A total of 116 patients with DM without abnormal electrocardiographic findings or evidence of peripheral arterial disease (number of risk factors > or =2; 62 +/- 7 years, 59% men) underwent CCTA and SPECT. Of the 116 patients with DM, 88 (76%) had a normal single photon emission computed tomographic findings, and 28 (24%) had abnormal perfusion defects. Of the 116 patients, 92 (79%) had atherosclerotic plaques (2 +/- 2 segments per subject), and 20 (17%) had significant stenosis seen on CCTA. Patients with DM and normal findings on SPECT had a similar prevalence of atherosclerotic plaque (78% vs 82%), significant stenosis (15% vs 25%), severe stenosis (7% vs 7%), and calcified (40% vs 43%), mixed (49% vs 57%), and noncalcified plaques (26% vs 29%) and a high (>100) coronary artery calcium score (32% vs 29%; all p >0.05) compared to those with abnormal findings on SPECT. During the mid-term follow-up (24 +/- 4 months), 5 cardiac events occurred in patients with DM and normal findings on SPECT, only in those with occult CAD on CCTA: 1 sudden cardiac death and 4 revascularization procedures. In conclusion, a significant percentage of patients with DM and normal eletrocardiographic findings, no peripheral arterial disease, and normal findings on SPECT have evidence of occult CAD on CCTA. Furthermore, a small percentage had had a cardiac event by mid-term follow-up. SPECT showed limited capability to differentiate the coronary risks between patients with DM and no coronary plaque and from those with a certain degree of disease; 2 circumstances that represent different coronary risks.