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Screening for Coronary Artery Disease in Patients with Diabetes

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Screening for Coronary Artery Disease in Patients with Diabetes Reviews/Commentaries/ADA Statements CONSENSUS STATEMENT Screening for Coronary Artery Disease in Patients With Diabetes 1 4 JEROEN J. BAX, MD, PHD ROBERT O. BONOW, MD controlled trials was lacking. However, 2 5 LAWRENCE H. YOUNG, MD HELMUT O. STEINBERG, MD the perceived high prevalence of adverse 3 6 ROBERT L. FRYE, MD EUGENE J. BARRETT, MD, PHD cardiac outcomes underscored the need for considering diagnostic testing. The panel also suggested that additional re- Coronary artery disease (CAD) accounts for a large fraction of the morbidity, mortality, and cost search should be conducted to evaluate of diabetes. Recognizing this, nearly 10 years ago the American Diabetes Association published the recommendations articulated. a consensus recommendation that clinicians consider a risk factor–guided screening approach to Over the past 10 years, there has been early diagnosis of CAD in both symptomatic and asymptomatic patients. Subsequent clinical trial a greatly increased recognition, both in results have not supported those recommendations. Since the prior consensus statement, newer the medical community and among pa- imaging methods, such as coronary artery calcium scoring and noninvasive angiography with tients, of the prevalence and impact of computed tomography (CT) techniques, have come into use. These technologies, which allow quantitation of atherosclerotic burden and can predict risk of cardiac events, might provide an CAD among patients with diabetes. The approach to more widespread coronary atherosclerosis screening. However, over this same time complicity of both conventional and in- interval, there has been recognition of diabetes as a cardiovascular disease (CVD) equivalent, flammatory risk markers in this increased clear demonstration that medical interventions should provide primary and secondary CVD risk risk has been extensively explored (3). reduction in diabetic populations, and suggestive evidence that percutaneous coronary revas- Perhaps most importantly, the benefit of cularization may not provide additive survival benefit to intensive medical management in both primary and secondary CVD risk patients with stable CAD. This additional evidence raises the question of whether documenting factor modification on cardiac outcomes asymptomatic atherosclerosis or ischemia in people with diabetes is warranted. More data has been proven in prospective interven- addressing this issue will be forthcoming from the BARI 2-D (Bypass Angioplasty Revascular- tional studies (4–9), and these results ization Investigation 2 Diabetes) trial. Until then, for patients with type 2 diabetes who are asymptomatic for CAD, we recommend that testing for atherosclerosis or ischemia, perhaps with have driven new guidelines for care in di- cardiac CT as the initial test, be reserved for those in whom medical treatment goals cannot be abetes (10). This may now be favorably met and for selected individuals in whom there is strong clinical suspicion of very-high-risk affecting population risks for events, at CAD. Better approaches to identify such individuals based on readily obtained clinical variables least in those with adequate access to care. are sorely needed. In clinical practice, the improved out- comes of aggressive medical therapy (11) Diabetes Care 30:2729–2736, 2007 are modifying the approach to treatment of patients with symptomatically less se- s coronary artery disease (CAD) is ing, and most critically, which patients vere CAD. the major cause of morbidity, mor- are particularly appropriate to be tested, Several studies of asymptomatic type A tality, and medical cost of diabetes the consensus panel recommended spe- 2 diabetic patients have specifically exam- (1), early diagnosis of CAD to prevent cialized CAD screening for patients ined whether risk factor burden (i.e., progression and clinical events has intui- thought to be at high risk. For the CAD number of risk factors) is predictive of in- tive appeal. In February 1998, the Amer- asymptomatic diabetic patient, the panel ducible ischemia (as determined by myo- ican Diabetes Association (ADA) particularly focused on risk factor burden cardial perfusion imaging), and these convened an expert panel to develop con- (i.e., the number of risk factors, not the have not supported the recommendation sensus positions addressing a series of severity of any one), baseline electrocar- of the 1998 consensus panel for screening questions related to coronary heart dis- diogram (ECG), and whether there was asymptomatic patients with two or more ease in both symptomatic and asymptom- clinical evidence of vascular disease at risk factors (12–14). At the same time, atic patients with diabetes (2). After other sites. The panel recognized that the evidence has accumulated regarding discussing the potential value of early di- positions articulated represented expert newer CAD diagnostic modalities, e.g., agnosis, the types and frequency of test- opinion, since evidence from well- CT angiography (15), coronary artery cal- ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● cium scoring (16,17), and cardiac mag- netic resonance imaging (18), that are From the 1Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; the 2Departments of Medicine and Physiology, Section of Cardiovascular Medicine, Yale University School of being implemented in strategies to diag- Medicine, New Haven, Connecticut; the 3Department of Medicine, Cardiovascular Division, Mayo Clinic nose and stage CAD. These modalities College of Medicine, Rochester, Minnesota; the 4Department of Medicine, Division of Cardiology, North- likely have implications for diabetic as western University Feinberg School of Medicine, Chicago, Illinois; the 5Department of Medicine, Division of well as nondiabetic patients (2). How- 6 Endocrinology and Metabolism, Indiana University, Indianapolis, Indiana; and the Department of Medi- ever, data that could provide a robust “ev- cine, Division of Endocrinology and Metabolism, University of Virginia, Charlottesville, Virginia. Address correspondence and reprint requests to Eugene Barrett, MD, PhD, University of Virginia, Box idence-based” recommendation for CAD 801410, Charlottesville, VA 22903. E-mail: [email protected]. testing in diabetic patients are not avail- Abbreviations: ADA, American Diabetes Association; CAD, coronary artery disease; CT, computed able. Recognizing these issues, the ADA tomography; CVD, cardiovascular disease; ECG, electrocardiogram; MI, myocardial infarction. recently convened an expert panel that A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion factors for many substances. revisited the issue of screening for CAD in DOI: 10.2337/dc07-9927. diabetic patients. The panel approached © 2007 by the American Diabetes Association. this by addressing four specific questions: DIABETES CARE, VOLUME 30, NUMBER 10, OCTOBER 2007 2729 Screening for CAD in diabetic patients 1. Which patients with diabetes are at in- cal surveillance, or revascularization of warrant careful consideration for identi- creased risk for adverse cardiovascular their CAD. However, clinical factors that fying patients at risk for events. outcomes? confer risk for adverse cardiac outcomes Other atherosclerotic vascular disease. 2. What are the implications of an early do not always predict which patients will Clinically evident atherosclerotic disease diagnosis of coronary ischemia or ath- have abnormal screening tests (13,14), involving lower-extremity, cerebral, re- erosclerosis? and negative screening tests in patients nal, or mesenteric arteries identifies a pa- 3. What tests, or sequence of tests, with diabetes do not uniformly confer a tient with diabetes who is at increased risk should be considered? With what fre- benign prognosis (20,21). Tests that de- for adverse cardiovascular outcomes and quencies should testing be done? tect inducible ischemia or assess athero- might have advanced coronary athero- 4. What further research is needed to sclerotic burden do not always identify sclerosis (24). In patients with claudica- evaluate the effectiveness of these rec- those patients at risk for plaque rupture tion or asymptomatic peripheral arterial ommendations? and thrombosis, which typically leads to disease, 90% of deaths are attributable to acute coronary events. Further research CAD (25). Clinical history is important to The goal was to provide practitioners with focusing on the biological properties of the determine the presence of vascular symp- information on the role of specialized car- vessel wall is needed to identify individuals toms (transient ischemic attack, mesen- diac testing in their CAD asymptomatic at high risk for acute coronary events, and teric ischemia, or claudication), as is the diabetic patients, recognizing that dia- such evidence might in the future guide physical exam for bruits and peripheral betic patients with CAD symptoms are treatment in asymptomatic individuals. pulses. A diminished ankle-brachial in- typically referred for cardiac testing. The Patients with clinical CAD are gener- dex is a sensitive indicator of increased panel recognized that some patients, who ally classified into three categories: low risk for future CVD events (26). may be at high risk for CAD, do not have risk, with a cardiac mortality risk Ͻ1% Microalbuminuria and chronic kidney access to care that would allow them to per year; high risk, with a cardiac mortal- disease. Microalbuminuria predicts in- benefit from this guidance
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