Identification of coronary heart disease in asymptomatic individuals with diabetes mellitus: to screen or not to screen.

Coronary heart disease (CHD) is highly prevalent in patients with diabetes mellitus (DM), and remains the single most common cause of death among this population. Regrettably, a significant percentage of diabetics fail to perceive the classic symptoms associated with myocardial ischemia. Among asymptomatic diabetics, the prevalence of abnormal cardiac testing appears to be high, ranging between 10% and 62%, and mortality is significantly higher in those with abnormal scans. Hence, the potential use of screening for CHD detection among asymptomatic DM individuals is appealing and has been recommended in certain circumstances. However, it was not until recently, that this question was addressed in clinical trials. Two studies randomized a total of 2,023 asymptomatic diabetics to screening or not using cardiac imaging with a mean follow up of 4.4 ± 1.4 years. In combination, both trials showed lower than expected annual event rates, and failed to reduce major cardiovascular events in the screened group compared to the standard of care alone. The results of these trials do not currently support the use of screening tools for CHD detection in asymptomatic DM individuals. However, these studies have important limitations, and potential explanations for their negative results that are discussed in this manuscript.

La enfermedad de la arterias coronarias (EAC) es muy prevalente en pacientes con diabetes mellitus (DM), y continúa siendo la principal causa de muerte en estos pacientes. Desafortunadamente, muchos diabéticos pueden carecer de síntomas de alerta en la presencia de isquemia miocárdica, por lo cual el diagnóstico de EAC puede ocurrir de manera tardía. Estudios observacionales han sugerido que la prevalencia de isquemia miocárdica puede ser alta en diabéticos asintomáticos (10 al 62% según la serie) y la mortalidad es mayor en esos pacientes. Por esto, el uso de pruebas para detección de EAC en el paciente diabético asintomático parece atractivo y es recomendado en ciertas circunstancias. Sin embargo, no fue si no hasta hace poco que dos estudios investigaron el verdadero rol de estas pruebas de manera aleatoria. En conjunto, 2,023 pacientes diabéticos asintomáticos fueron aleatorizados a recibir o no una prueba para detección de EAC y fueron seguidos en promedio por 4.4 ± 1.4 años. Al final de seguimiento, ambos estudios mostraron menos eventos cardiovasculares de los esperados, y el uso de pruebas para detección de EAC no redujo la tasa de eventos cardiovasculares comparado al no uso de estas pruebas. Los resultados de estos ensayos clínicos no soportan actualmente el uso de estas pruebas en el paciente diabético asintomático. Sin embargo, estos estudios tienen limitaciones importantes, y posibles hipótesis para explicar los resultados que son discutidas en el artículo.

Identification of coronary heart disease in asymptomatic individuals with diabetes mellitus: to screen or not to screen / Identificación de enfermedad cardiaca coronaria en individuos asintomáticos con diabetes mellitus: Tamizar o no tamizar

Coronary heart disease (CHD) is highly prevalent in patients with diabetes mellitus (DM), and remains the single most common cause of death among this population. Regrettably, a significant percentage of diabetics fail to perceive the classic symptoms associated with myocardial ischemia. Among asymptomatic diabetics, the prevalence of abnormal cardiac testing appears to be high, raging between 10% and 62%, and mortality is significantly higher in those with abnormal scans. Hence, the potential use of screening for CHD detection among asymptomatic DM individuals is appealing and has been recommended in certain circumstances. However, it was not until recently, that this question was addressed in clinical trials. Two studies randomized a total of 2,023 asymptomatic diabetics to screening or not using cardiac imaging with a mean follow up of 4.4 ±1.4 yrs. In combination, both trials showed lower than expected annual event rates, and failed to reduce major cardiovascular events in the screened group compared to the standard of care alone. The results of these trials do not currently support the use of screening tools for CHD detection in asymptomatic DM individuals. However, these studies have important limitations, and potential explanations for their negative results that are discussed in this manuscript.

La enfermedad de la arterias coronarias (EAC) es muy prevalente en pacientes con diabetes mellitus (DM), y continúa siendo la principal causa de muerte en estos pacientes. Desafortunadamente, muchos diabéticos pueden carecer de síntomas de alerta en la presencia de isquemia miocárdica, por lo cual el diagnóstico de EAC puede ocurrir de manera tardía. Estudios observacionales han sugerido que la prevalencia de isquemia miocárdica puede ser alta en diabéticos asintomáticos (10 al 62% según la serie) y la mortalidad es mayor en esos pacientes. Por esto, el uso de pruebas para detección de EAC en el paciente diabético asintomático parece atractivo y es recomendado en ciertas circunstancias. Sin embargo, no fue si no hasta hace poco que dos estudios investigaron el verdadero rol de estas pruebas de manera randomizada. En conjunto, 2,023 pacientes diabéticos asintomáticos fueron aleatorizados a recibir o no una prueba para detección de EAC y fueron seguidos en promedio por 4.4 ±1.4 años. Al final de seguimiento, ambos estudios mostraron menos eventos cardiovasculares de los esperados, y el uso de pruebas para detección de EAC no redujo la tasa de eventos cardiovasculares comparado al no uso de estas pruebas. Los resultados de estos ensayos clínicos no soportan actualmente el uso de estas pruebas en el paciente diabético asintomático. Sin embargo, estos estudios tienen limitaciones importantes, y posibles hipótesis para explicar los resultados que son discutidas en el artículo.

Incremental prognostic value of kidney function decline over coronary artery disease for cardiovascular event prediction after coronary computed tomography.

It is unknown whether mild chronic kidney disease (CKD) is associated with adverse cardiovascular (CV) prognosis after accounting for coronary artery disease (CAD). Here we evaluated the interplay between CKD and CAD in predicting CV death or myocardial infarction (MI) and all-cause death. We included 1541 consecutive patients in the Partners registry (mean age 55 years, 43% female) over 18 years old with no known prior CAD who underwent coronary computed tomography angiography (CCTA). The results of CCTA were categorized as normal, nonobstructive (under half), or obstructive (half and over). Overall, 653 of the patients had no CAD, 583 had nonobstructive CAD, and 305 had obstructive CAD, while 1299 had eGFR over 60 ml/min per 1.73 m(2) and 242 had an eGFR under this value. The presence and severity of CAD was significantly associated with an increased rate of CV death or MI and all-cause death, even after adjustment for age, gender, symptoms, and risk factors. Similarly, reduced eGFR was significantly associated with CV death or MI and all-cause death after similar adjustment. The addition of reduced GFR to a model which included both clinical variables and CCTA findings resulted in significant improvement in the prediction of CV death or MI and all-cause death. Thus, among individuals referred for CCTA to evaluate CAD, renal dysfunction is associated with an increased rate of CV events, mainly driven by an increase in the rate of noncoronary CV events. In this group of patients, both eGFR and the presence and severity of CAD together improve the prediction of future CV events and death.

Electrocardiographic infarct size assessment after thrombolysis: insights from the Acute Myocardial Infarction STudy ADenosine (AMISTAD) trial.

BACKGROUND: Noninvasive methods are needed to evaluate reperfusion success in patients with acute myocardial infarction (MI). The AMISTAD trial was analyzed to compare MI size and myocardial salvage determined by electrocardiogram (ECG) with technetium Tc 99m sestamibi single-photon emission computerized tomography (SPECT) imaging. METHODS: Of 236 patients enrolled in AMISTAD, 166 (70 %) with no ECG confounding factors and no prior MI were included in this analysis. Of these, group 1 (126 patients, 53%) had final infarct size (FIS) available by both ECG and SPECT. Group 2 (56 patients, 24%) had myocardium at risk, FIS, and salvage index (SI) assessed by both SPECT and ECG techniques. Aldrich/Clemmensen scores for myocardium at risk and the Selvester QRS score for final MI size were used. Salvage index was calculated as follows: SI = (myocardium at risk-FIS)/(myocardium at risk). RESULTS: In group 1, FIS was 15% (6, 24) as measured by ECG and 11% (2, 27) as measured by SPECT. In the adenosine group, FIS was 12% (6, 21) and 11% (2, 22). In the placebo group, FIS was 16.5% (7.5, 24) and 11.5% (3.0, 38.5) by ECG and SPECT, respectively. The overall correlation between SPECT and ECG for FIS was 0.58 (P = .0001): 0.60 in the placebo group (P = .0001) and 0.54 (P = .0001) in the adenosine group. In group 2, myocardium at risk was 23% (17, 30) and 26% (10, 50) with ECG and SPECT, respectively (P = .0066). Final infarct size was 17% (6, 21) and 12% (1, 24) (P < .0001). The SI was 29% (-7, 57) and 46% (15, 79) with ECG and SPECT, respectively (P = .0510). CONCLUSIONS: The ECG measurement of infarct size has a moderate relationship with SPECT infarct size measurements in the population with available assessments. This ECG algorithm must further be validated on clinical outcomes.