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© 2004 by the American Diabetes Association, Inc.
Pathophysiology/Complications |
Detection of Silent Myocardial Ischemia in Asymptomatic Diabetic Subjects
The DIAD study
1 Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
2 Section of Endocrinology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
3 Yale University School of Nursing, New Haven, Connecticut
4 Department of Medicine/Endocrinology, University of Virginia, Charlottesville, Virginia
5 Department of Nuclear Medicine, University of Montreal, Montreal, Canada
6 Department of Medicine/Endocrinology, University of Rochester, Rochester, New York
7 Hartford Hospital, Hartford, Connecticut
8 Cardiology Consultants, Calgary, Canada
9 Soundview Research Associates, Norwalk, Connecticut
10 MedStar Research Institute, Washington, DC
11 Department of Medicine/Cardiovascular Disease, University of Alabama, Birmingham, Alabama
Address correspondence and reprint requests to Frans J. Th. Wackers, MD, Yale University School of Medicine, Section of Cardiovascular Medicine, 333 Cedar St., Fitkin-3, New Haven, CT 06520. E-mail: frans.wackers{at}yale.edu
OBJECTIVE—To assess the prevalence and clinical predictors of silent myocardial ischemia in asymptomatic patients with type 2 diabetes and to test the effectiveness of current American Diabetes Association screening guidelines.
RESEARCH DESIGN AND METHODS—In the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study, 1,123 patients with type 2 diabetes, aged 50–75 years, with no known or suspected coronary artery disease, were randomly assigned to either stress testing and 5-year clinical follow-up or to follow-up only. The prevalence of ischemia in 522 patients randomized to stress testing was assessed by adenosine technetium-99m sestamibi single-photon emission–computed tomography myocardial perfusion imaging.
RESULTS—A total of 113 patients (22%) had silent ischemia, including 83 with regional myocardial perfusion abnormalities and 30 with normal perfusion but other abnormalities (i.e., adenosine-induced ST-segment depression, ventricular dilation, or rest ventricular dysfunction). Moderate or large perfusion defects were present in 33 patients. The strongest predictors for abnormal tests were abnormal Valsalva (odds ratio [OR] 5.6), male sex (2.5), and diabetes duration (5.2). Other traditional cardiac risk factors or inflammatory and prothrombotic markers were not predictive. Ischemic adenosine-induced ST-segment depression with normal perfusion (n = 21) was associated with women (OR 3.4). Selecting only patients who met American Diabetes Association guidelines would have failed to identify 41% of patients with silent ischemia.
CONCLUSIONS—Silent myocardial ischemia occurs in greater than one in five asymptomatic patients with type 2 diabetes. Traditional and emerging cardiac risk factors were not associated with abnormal stress tests, although cardiac autonomic dysfunction was a strong predictor of ischemia.
Abbreviations: ADA, American Diabetes Association • CAD, coronary artery disease • DIAD, Detection of Ischemia in Asymptomatic Diabetics • ECG, electrocardiogram • SPECT, single-photon emission–computed tomography
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