Detection Of Silent Myocardial Ischemia Research Articles

Silent Myocardial Ischemia in Type 2 Diabetic Patients Asymptomatic For Coronary Artery Disease: A Cross- Sectional Study

Background Coronary Artery Disease (CAD) is a common cause of premature morbidity and mortality in diabetics and is often asymptomatic because of silent myocardial ischemia (SMI). Early detection of SMI may prevent catastrophic cardiac events. Objective To study the prevalence of SMI in patients of type 2 diabetes mellitus (Type 2 DM), asymptomatic for CAD and to assess the role of conventional CAD risk factors in diabetic patients asymptomatic for CAD in the development of SMI. Methodology 102 cases of Type 2 DM without any clinical and electrocardiographic evidence of CAD, who attended a tertiary care hospital in North Delhi, over a period of one year, were studied for the present cross-sectional study. Detailed history, general physical examination, BMI, systemic examination and investigations like glycosylated hemoglobin (HbA1c), lipid profile, resting 12-leads electrocardiography (ECG) and treadmill test (TMT) were carried out. Results Out of 102 patients, TMT was found positive in 23 patients. It was positive in 12% among diabetic patients with duration of diabetes ≤5 years, 14.8% in patients with duration 6-10 years, 37.5% in patients with duration 10-15 years and 77.7% in patients with duration 16-20 years, respectively with p<0.001. Conclusion The prevalence of SMI in asymptomatic Type 2 DM without history of CAD is 22.54%. Duration of diabetes, presence of autonomic neuropathy (AN), dyslipidemia and HbA1c level are strong clinical predictors of SMI in asymptomatic Type 2 DM. Keywords: Silent myocardial ischemia; Type 2 Diabetes mellitus; Coronary artery Disease; Treadmill test Asymptomatic; Autonomic Neuropathy.

P979 Subclinical left ventricular dysfunction and silent myocardial ischemia in asymptomatic middle-aged patients with type 2 diabetes mellitus

Abstract Early detection of silent myocardial ischemia (SMI) in asymptomatic middle-aged patients (pts) with type 2 diabetes mellitus (T2DM) may be important due to the generally poor prognosis and early myocardial involvement in this specific subgroup of diabetic population. Our goal was to evaluate whether subclinical left ventricular (LV) systolic dysfunction assessed by two-dimensional speckle-tracking echocardiography (2D-STE) is independently related to SMI detected by MPI (gated SPECT myocardial scintigraphy) and if it could provide incremental information over baseline characteristics to identify it. We have tested the hypothesis that the myocardial mechanics significantly differ in asymptomatic middle-aged diabetics, depending on the presence or absence of SMI. In total, 60 consecutive middle-aged (<60 years; 42 males, 70.0%) asymptomatic T2DM pts were enrolled into the study. MPI was performed in one-day protocol according to the EANM procedural guidelines, and SMI was diagnosed consensually by two experts as myocardial perfusion abnormalities without associated symptoms. The T2DM pts were subdivided into two groups according to the results of MPI, namely SMI group (n = 11) and non-SMI group (n= 49) Global longitudinal peak systolic strain (GLPSS) was measured from two- and four-chamber views cines using Automated Function Imaging (Vivid S6, GE). Subclinical LV dysfunction was defined as GLPSS of > -20%. Prevalence of SMI in T2DM pts was 18,3%. All pts in SMI group (n = 11) were of male gender, and disease duration ≥ 5 years. Pooled data from 2D-STE showed significant reduction in mean absolute GLPSS values (p<.001). Further more, pts in SMI group had more impaired GLPSS when compared with patients in non-SMI group (-16.1 ± 1.5% vs. -20.4 ± 1.8%, P < .01). At multivariate analysis, male gender, an amount of epicardial adipose tissue and erectile dysfunction in men were independently associated with SMI. The addition of the LV GLPSS values to other selected independent clinical variables significantly improved the ability to predict SMI in these patients (χ(2) = 48.62; P = .001). Asymptomatic middle-aged T2DM pts with SMI showed a more impaired LV GLPSS compared with patients without silent ischemia. The presence of subclinical LV systolic dysfunction provides significant incremental value for the identification of SMI in asymptomatic middle-aged diabetics.

TCTAP C-020 Treatment of AMI in the LCx Basin and AMI LAD Caused by Translocation of the Left Circumflex Thrombus Followed by PCI of the LAD During the Same Hospitalization for Detection of Silent Myocardial Ischemia

### Patient initials or identifier number U ### Relevant clinical history and physical exam Patient U, 58 years admitted to the hospital with chest pain (left side). Background and Risk factors: CHD. MI 08. 2011, 11. 2011 (anterolateral wall) Arterial Hypertension 3 risk 4. CHF 2-3 (NYHA) CKD

The Benefit of Dobutamine Stress Echocardiography in the Detection of Silent Myocardial Ischemia in NonDiabetic Hemodialysis Patients

The Benefit of Dobutamine Stress Echocardiography in the Detection of Silent Myocardial Ischemia in NonDiabetic Hemodialysis Patients

Ambulatory 24-h ECG monitoring and cardiovascular autonomic assessment for the screening of silent myocardial ischemia in elderly type 2 diabetic hypertensive patients.

The aim of the study was to evaluate the usefulness of Holter monitoring for the detection of silent myocardial ischemia (SMI) in elderly type 2 diabetic patients with hypertension and the possible relationship between SMI and cardiovascular autonomic neuropathy (CAN). Two hundred and forty-three asymptomatic outpatients, aged 65-75years, with type 2 diabetes and essential hypertension underwent 24-h ECG monitoring and 5 tests for the evaluation of both parasympathetic (heart rate variability, response to breath deeping, and Valsalva manoeuvre) and sympathetic (cold pressor test and orthostatic hypotension test) autonomic function. A total of 518 asymptomatic episodes of ST depression during Holter monitoring indicative of SMI were detected in 51 of the 243 studied patients (20.9%). None of the patients with ST depression episodes exhibited a normal response to at least one of the evaluated autonomic function tests, whereas 22 of the 192 patients without ST changes (11.4%) exhibited a normal response to all tests. Abnormality in both parasympathetic and sympathetic function test responses was found in 94.1% of patients with ST depression episodes vs 26.1% of those without ST changes (P<0.001). Statistical evaluation of the relationship between the abnormal response to single autonomic function test and episodes of ST depression was highly significant for all the 5 tests (P<0.001). These results indicate that: (a) Holter monitoring enables to detect ST segment changes indicative of SMI in 20.9% of elderly diabetic patients with hypertension; (b) the presence of autonomic cardiac dysfunction in these patients suggests a role of diabetic neuropathy in the pathogenesis of SMI; and

Detection of silent myocardial ischaemia in type 2 diabetes mellitus by exercise treadmill test

Detection of silent myocardial ischaemia in type 2 diabetes mellitus by exercise treadmill test

The Utility of Carotid Ultrasonography in Identifying Severe Coronary Artery Disease in Asymptomatic Type 2 Diabetic Patients Without History of Coronary Artery Disease

OBJECTIVEAlthough many studies have shown that carotid intima-media thickness (IMT) is associated with coronary artery disease (CAD), it remains inconclusive whether assessment of carotid IMT is useful as a screening test for asymptomatic but severe CAD in diabetic patients.RESEARCH DESIGN AND METHODSA total of 333 asymptomatic type 2 diabetic patients without history of CAD underwent exercise electrocardiogram or myocardial perfusion scintigraphy for detection of silent myocardial ischemia, and those whose test results were positive were subjected to coronary computed tomography angiography or coronary angiography. The ability of carotid IMT to identify severe CAD corresponding to treatment with revascularization was examined by receiver-operating characteristic (ROC) curve analyses.RESULTSAmong the 333 subjects, 17 were treated with revascularization. A multiple logistic regression analysis showed that maximum IMT was an independent predictor of severe CAD even after adjustment for conventional risk factors. ROC curve analyses revealed that the addition of maximum IMT to conventional risk factors significantly improved the prediction ability for severe CAD (from area under the curve, 0.67 to 0.79; P = 0.039). The greatest sensitivity and specificity were obtained when the cut-off value of maximum IMT was set at 2.45 mm (pretest probability, 5%; posttest probability, 11%; sensitivity, 71%). When we applied age-specific cut-off values, the sensitivity of screening further increased in both the nonelderly (pretest probability, 6%; posttest probability, 10%; sensitivity, 100%) and the elderly subjects (pretest probability, 5%; posttest probability, 15%; sensitivity, 100%).CONCLUSIONSOur study suggests that carotid maximum IMT is useful for screening asymptomatic type 2 diabetic patients with severe CAD equivalent to revascularization.

P 5: Value of the UKPDS risk score in the screening of asymptomatic type 2 diabetic patients for coronary stenoses and artery stiffness

Rationale and aims In patients with type 2 diabetes silent coronary disease was shown to be predictive of major cardiac events. Thus, the detection of silent myocardial ischemia (SMI) and silent coronary stenoses is challenging. Artery stiffness is also associated with a worse prognosis. The aim of this study was to examine the value of the UKPDS risk score for coronary events in the algorithm of screening for SMI, coronary stenoses and artery stiffness in patients with type 2 diabetes. Patients and Methods We included 116 patients (65 women and 51 men), aged 55.4 ± 11.8 years, without known cardiovascular disease and with normal resting ECG but at high cardiovascular risk. SMI was assessed on an ECG stress test, and a coronary angiography was carried out in the patients with SMI. Significant coronary stenoses (SCS) were defined as ≥ 70% (or 50% for the main left coronary artery). The 10-year coronary risk of non fatal events was estimated using the UKPDS risk engine. Aortic pulse wave velocity (PWV) was measured (CompliorO). Results The prevalence of hypertension, obesity, dyslipidemia, nephropathy and smoking was 61.2%, 47.2%, 52.6%, 36.2 and 6%, respectively. SMI was found in 59 patients. A coronary angiography was performed in 51 of them, and 22 (15 men and 7 women) had SCS. The coronary risk score was 18.8±16.0%, and was significantly higher in men than in women (29.4±18.3% vs 10.6±6.8%, p Conclusion In this population of type 2 diabetic patients at high cardiovascular risk, an UKPDS risk score for non fatal coronary events ≥ 15% was associated with a significantly increased risk of artery stiffness and silent coronary stenoses. This score may help in screening patients who should be tested for these disorders.

Detection of Silent Myocardial Ischaemia in Asymptomatic Diabetic Patients during Treadmill Exercise Testing

Diabetic patients have an increased prevalence of atherosclerosis and coronary artery disease. They may also experience higher morbidity and mortality after acute coronary syndrome compared with non-diabetic subjects. The objective of this study was to determine the presence of silent myocardial ischaemia by treadmill test in asymptomatic diabetic patients and to compare it with age- and sex-matched subjects without diabetes mellitus. The study design was cross-sectional and the setting was a tertiary care centre. Fifty (42 males, 8 females) asymptomatic patients with diabetes in the age group of 30-70 years were included in the study group and 30 (24 males, 6 females) non-diabetic subjects of comparable age, sex and physical activity were the control group. They were assessed for the presence of silent ischaemia by a standard treadmill test using the Bruce protocol. Twenty-five of 50 diabetic patients showed a positive response to the exercise stress test, while 7 of 30 controls showed stress test positivity (p < 0.05). The stress test positivity showed a female predilection among diabetic patients (50% in diabetic patients and 16.67% in controls; p < 0.05). Diabetic patients with a positive stress test showed higher prevalence of hypertension (36%) and dyslipidaemia (84%) compared with diabetic patients with a negative stress test (12% and 28%, respectively) [p < 0.001]. The controls showed a better exercise capacity compared with diabetic patients; diabetic patients with a negative stress test had better exercise capacity than those with a positive stress test. The treadmill test is a useful, specific, cost-effective, non-invasive tool for detection of silent myocardial ischaemia in asymptomatic diabetic patients.

Detection of Silent Myocardial Ischaemia in Asymptomatic Diabetic Patients during Treadmill Exercise Testing

Detection of Silent Myocardial Ischaemia in Asymptomatic Diabetic Patients during Treadmill Exercise Testing

Detection of silent myocardial ischemia in asymptomatic patients with diabetes: results of a randomized trial and meta-analysis assessing the effectiveness of systematic screening.

BackgroundMost guidelines recommend a systematic screening of asymptomatic high risk patients with diabetes for silent ischemia, but the clinical benefit of this strategy has not been demonstrated compared with the simple control of cardiovascular risk factors. We sought to determine whether referring asymptomatic diabetic patients for screening of silent ischemia decreases the risk of cardiovascular events compared with usual care.MethodsDYNAMIT was a prospective, randomized, open, blinded end-point multicenter trial run between 2000 and 2005, with a 3.5 year mean follow-up in ambulatory care in 45 French hospitals. The study included 631 male and female with diabetes aged 63.9 ± 5.1 years, with no evidence of coronary artery disease and at least 2 additional cardiovascular risk factors, receiving appropriate medical treatment. The patients were randomized centrally to either screening for silent ischemia using a bicycle exercise test or Dipyridamole Single Photon Emission Computed Tomography (N = 316), or follow-up without screening (N = 315). The main study end point was time to death from all causes, non-fatal myocardial infarction, non-fatal stroke, or heart failure requiring hospitalization or emergency service intervention. The results of a meta-analysis of DYNAMIT and DIAD, a similar study, are also presented.ResultsThe study was discontinued prematurely because of difficulties in recruitment and a lower-than expected event rate. Follow-up was complete for 98.9% patients regarding mortality and for 97.5% regarding the main study end point. Silent ischemia detection procedure was positive or uncertain in 68 (21.5%) patients of the screening group. There was no significant difference between the screening and the usual care group for the main outcome (hazard ratio = 1.00 95%CI 0.59 to 1.71). The meta-analysis of these and DIAD results gave similar results, with narrower confidence intervals for each endpoint.ConclusionsThese results suggest that the systematic detection of silent ischemia in high-risk asymptomatic patients with diabetes is unlikely to provide any major benefit on hard outcomes in patients whose cardiovascular risk is controlled by an optimal medical treatment.Trial registrationClinicalTrials.gov: NCT00627783

A randomized study comparing isotope and echocardiography stress testing in the screening of silent myocardial ischaemia in type 2 diabetic patients

Aims This study aimed to compare the positive predictive value (PPV) of stress myocardial scintigraphy (SPECT) and of dobutamine echocardiography (DE) in the diagnosis of significant coronary artery stenosis (CAD) in asymptomatic type 2 diabetic patients, and to assess long-term clinical outcomes according to silent myocardial ischaemia (SMI) screening. Methods A total of 204 asymptomatic type 2 diabetic patients at high cardiovascular (CV) risk were prospectively randomized to undergo either SPECT ( n = 104) or DE ( n = 100). Coronary angiography was proposed in cases of SMI, with revascularization of suitable lesions. Intensive treatment of CV risk factors was prescribed for all patients. Death and myocardial infarction (MI) were recorded during the 3-year follow-up. Results Clinical characteristics were similar in the two testing groups. The prevalence of SMI and significant CAD were 13% and 4%, respectively, in the SPECT group vs 11% and 5%, respectively, in the DE group (not significant [NS]). The PPV for the detection of significant CAD was 29% for SPECT and 45% for DE (NS). Seven patients (3%) underwent initial revascularization. The 3-year rate of CV death and MI was 2.5%, and similar in both groups. Conclusion Rates of SMI and significant CAD in asymptomatic high-risk type 2 diabetic patients receiving intensive care of risk factors are low, and SPECT and DE are similar in the detection of SMI and CAD. Coronary revascularization and intensive CV risk-factor therapy are associated with a low rate of adverse CV events at 3 years, whichever stress test was used.

Dépistage de l’ischémie myocardique par l’échocardiographie de stress à la dobutamine chez le diabétique de type 2 à haut risque cardiovasculaire au Sénégal

Introduction Diabetes is a major risk factor for coronary artery disease witch may develop insidiously. Several non-invasive methods are used to detect silent myocardial ischaemia, especially in diabetic patients at high cardiovascular risk. We project to screen, by dobutamine stress echocardiography, silent myocardial ischaemia in type 2 diabetics in Senegal. Methodology We randomly recruited in hospital in Senegal type 2 diabetics aged at least 40 years and a dobutamine stress echocardiography was performed in those selected according to the French Society of Cardiology and the French Language Association for the Study of Diabetes and Metabolic Diseases. Results Dobutamine stress echocardiography was performed in 79 diabetics at high cardiovascular risk, including 56 women. The average age was 58.8 ± 11.8 years. The exam was positive in 67.1% of cases (53/79), with a predominance of motion abnormalities in anterior territory (83%). Cardiovascular risk factors associated with positivity of test were microalbuminuria ( p = 0.0001), inactivity ( p = 0.0001), dyslipidemia ( p = 0.0002), arterial hypertension ( p = 0.001), smoking (0.003) and male sex ( p = 0.004). Conclusion In Africa, dobutamine stress echocardiography has the advantage of its accessibility and its feasibility. Early detection of silent myocardial ischaemia in diabetics at high risk could optimize their care.

Langzeit-Elektrokardiographie

During the past almost 50 years Holter monitoring has become an established non-invasive diagnostic tool in clinical electrophysiology. It allows ECG recording independent of stationary monitoring facilities during daily life and, therefore, contains much information. In the beginning the main interest was directed towards quantitative and qualitative assessment of arrhythmias, their circadian behaviour, and the circadian behaviour of the heart rate. With advances in technology the analysis spectrum of Holter monitoring expanded, and it was used also for detection of silent myocardial ischaemia. New digital recorders and computers with large capacities made it possible to measure every single heart beat very accurately, which was a prerequisite for heart rate variability and QT-interval analysis, which provided new knowledge about the autonomic modulation of the heart rate and the circadian dynamicity of the QT interval, respectively. Beyond arrhythmia analysis Holter monitoring was increasingly used to assess prognosis in different cardiac conditions. It can also be valuable in assessing transient symptoms possibly related to arrhythmias or device dysfunction, which will not necessarily be revealed by simple device control.

Value of 99mTc-methoxyisobutylisonitrile (99mTc-MIBI) gated SPECT for the detection of silent myocardial ischemia in hemodialysis patients: clinical variables associated with abnormal test results

Although coronary artery disease is a major cause of mortality and morbidity in patients undergoing hemodialysis, there is no accurate diagnostic strategy for these patients. To assess the value of 99mTc-methoxyisobutylisonitrile (99mTc-MIBI) gated single-photon emission computed tomography for the detection of silent myocardial ischemia in patients undergoing hemodialysis and to evaluate the clinical variables associated with abnormal test results. Thirty-one asymptomatic patients undergoing hemodialysis (20 men, 11 women), with a mean age of 45 years (range, 25-75 years), were included in the study. Serum electrolytes, creatinine, homocysteine and adhesion molecules were measured prior to dialysis. Ambulatory blood pressure, carotid intima-media thickness measurements, echocardiography and stress 99mTc-MIBI imaging were performed in all patients, whereas coronary angiography was performed only in patients with abnormal myocardial perfusion scintigraphy and/or echocardiography. Gated myocardial perfusion scintigraphy results were abnormal in nine patients (29%) and coronary angiography was abnormal in six patients. After a median follow-up of 20 months (range, 14-28 months), nine patients experienced a cardiac event. Seven of the nine patients (78%) with abnormal myocardial perfusion scintigraphy suffered a cardiac event, compared with only two of 22 patients (9%) with normal myocardial perfusion scintigraphy (P<0.0001). Patients with abnormal perfusion scintigraphy had higher serum C-reactive protein, homocysteine and adhesion molecule levels and the duration of hemodialysis was significantly longer. In asymptomatic hemodialysis patients, gated myocardial perfusion scintigraphy is a safe and non-invasive screening technique for the detection of coronary artery disease and for predicting future cardiac events. The presence of ischemia correlates significantly with markers of inflammation. The discordant results (abnormal myocardial perfusion scintigraphy/normal coronary angiography) can be attributed to angiographically unrecognized occult atherosclerotic changes and abnormal vasodilatation capacity of the coronary circulation.

Mo-P5:323 Gated-spect in the detection of silent myocardial ischemia. Algorithm for the realization in type 2 diabetic patients

Mo-P5:323 Gated-spect in the detection of silent myocardial ischemia. Algorithm for the realization in type 2 diabetic patients

Assessing Cardiovascular Risk in Asymptomatic Diabetes: The DIAD Study

Wackers FJ, Young LH, Inzucchi SE, Chyun DA, Davey JA, Barrett EJ, Taillefer R, Wittlin SD, Heller GV, Filipchuk N, Engel S, Ratner RE, Iskandrian AE, the Detection of Ischemia in Asymptomatic Diabetics (DIAD) Investigators: Detection of silent myocardial ischemia in asymptomatic diabetic subjects. Diabetes Care27 : 1954-1961,2004 [OpenUrl][1][Abstract/FREE Full Text][2] Objective. To determine the prevalence and severity of inducible myocardial ischemia in asymptomatic patients with type 2 diabetes, aged 50-75 years, with normal electrocardiograms (ECGs), using adenosine-stress single photon emission-computed tomography (SPECT) myocardial perfusion imaging along with clinical and laboratory predictors of abnormal test results. Design. A randomized, open, prospective, clinical trial following patients for a period of 5 years to determine the prevalence and predictors of silent myocardial ischemia (SMI) in people with type 2 diabetes with no history of known coronary artery disease (CAD) and no cardiac symptoms. Approximately half of the subjects were randomized to adenosine-stress perfusion imaging at baseline and follow-up, and half were randomized to follow-up without imaging screening. End points. Prevalence, severity, and predictors of patients with SMI as defined by perfusion abnormalities on pharmacological stress perfusion imaging (adenosine-sestamibi SPECT). Results. Of 1,123 patients with type 2 diabetes aged 50-75 years without known or suspected CAD, 113 (22%) had silent ischemia. Eighty-three had regional myocardial perfusion abnormalities, and 30 had normal perfusion with other abnormalities. Moderate and large perfusion defects were present in 33 patients (6% of the screened cohort). Of those with perfusion abnormalities, 96% had some degree of reversibility indicative of ischemia. The strongest predictors … [1]: {openurl}?query=rft.jtitle%253DDiabetes%2BCare%26rft.stitle%253DDiabetes%2BCare%26rft.issn%253D0149-5992%26rft.aulast%253DWackers%26rft.auinit1%253DF.%2BJ.Th.%26rft.volume%253D27%26rft.issue%253D8%26rft.spage%253D1954%26rft.epage%253D1961%26rft.atitle%253DDetection%2Bof%2BSilent%2BMyocardial%2BIschemia%2Bin%2BAsymptomatic%2BDiabetic%2BSubjects%253A%2BThe%2BDIAD%2Bstudy%26rft_id%253Dinfo%253Adoi%252F10.2337%252Fdiacare.27.8.1954%26rft_id%253Dinfo%253Apmid%252F15277423%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=diacare&resid=27/8/1954&atom=%2Fdiaclin%2F23%2F3%2F126.atom

Stress myocardial scintigraphy and dobutamine echocardiography in the detection of coronary disease in asymptomatic patients with type 2 diabetes

The aims of this prospective study were: (1) to compare stress thallium-201 single photon emission computed tomography (SPECT) and dobutamine echocardiography (DE) in the detection of silent myocardial ischemia (SMI) in asymptomatic high risk diabetic patients; (2) to analyse long-term outcome after intensive care of SMI in these patients. SPECT was performed in 100 high risk diabetic patients and DE in the first 75 patients. Coronary angiography was realized in patients with SMI, with revascularization for suitable lesions. Intensive treatment of atherosclerosis risk factors was performed in all patients. Patients were followed 2 +/- 0.5 years for the subsequent occurrence of cardiac death, myocardial infarction and revascularization. SMI was detected by SPECT in 62% and by DE in 10% of the patients (p < 0.0001), whereas significant coronary stenosis at angiography was detected by SPECT in 26% and by DE in 5% of the patients (p < 0.02). Independent predictive factors of significant coronary stenosis were male gender (p < 0.03) and peripheral arterial disease (p < 0.007). Nonfatal acute coronary syndrome occurred during follow-up in 2 patients (2%). Subsequent revascularization procedure was needed in 9 patients. Baseline patients' characteristics, as well as SMI, were not predictive of cardiac event during follow up. SPECT seems more accurate than DE to detect significant coronary stenosis in high risk asymptomatic diabetic patients. In this population, aggressive treatment of SMI with systematic revascularization combined with intensive care of risk factors is associated with a favorable long-term prognosis, similar in diabetic patients with and without initial SMI.

Detection of Silent Myocardial Ischemia in Asymptomatic Diabetic Subjects

We were impressed by the results of the Detection of Silent Myocardial Ischemia in Asymptomatic Diabetic Subjects (DIAD) study (1), which found that silent myocardial ischemia (SMI) was present in 22% of a large cohort of asymptomatic patients with type 2 diabetes and that the strongest predictor for abnormal cardiac tests was an abnormal Valsalva test. We have also found that autonomic function predicts SMI but that abnormal sympathetic, rather than parasympathic, tests are predictive. We selected 12 patients with type 2 diabetes and 12 nondiabetic patients with documented exercise-induced electrocardiogram (ECG) changes (Bruce protocol) and angiographically proven coronary artery disease from the cardiac catheterization database of …

Detection of Silent Myocardial Ischemia in Asymptomatic Diabetic Subjects

We read the results of the DIAD study (1) with great interest and congratulate all of the investigators. However, the study leaves some questions unanswered and raises others. 1 ) Since there is no nondiabetic control group with similar baseline characteristics, we don’t know whether the reported prevalence of silent ischemia (22%) is higher than in nondiabetic patients. Such a comparison is necessary to determine how many scans are needed to diagnose one addional silent ischemia in asymptomatic diabetic patients. Therefore, the clinician is not assisted in determining whether performing …