Detection of Silent Myocardial Ischemia in Asymptomatic Diabetic Subjects
The DIAD study
- Frans J.Th. Wackers, MD1,
- Lawrence H. Young, MD1,
- Silvio E. Inzucchi, MD2,
- Deborah A. Chyun, PHD3,
- Janice A. Davey, MSN1,
- Eugene J. Barrett, MD4,
- Raymond Taillefer, MD5,
- Steven D. Wittlin, MD6,
- Gary V. Heller, MD7,
- Neil Filipchuk, MD8,
- Samuel Engel, MD9,
- Robert E. Ratner, MD10,
- Ami E. Iskandrian, MD11 and
- for the Detection of Ischemia in Asymptomatic Diabetics (DIAD) Investigators*
- 1Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- 2Section of Endocrinology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- 3Yale University School of Nursing, New Haven, Connecticut
- 4Department of Medicine/Endocrinology, University of Virginia, Charlottesville, Virginia
- 5Department of Nuclear Medicine, University of Montreal, Montreal, Canada
- 6Department of Medicine/Endocrinology, University of Rochester, Rochester, New York
- 7Hartford Hospital, Hartford, Connecticut
- 8Cardiology Consultants, Calgary, Canada
- 9Soundview Research Associates, Norwalk, Connecticut
- 10MedStar Research Institute, Washington, DC
- 11Department 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
Abstract
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.
- ADA, American Diabetes Association
- CAD, coronary artery disease
- DIAD, Detection of Ischemia in Asymptomatic Diabetics
- ECG, electrocardiogram
- SPECT, single-photon emission–computed tomography
Footnotes
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↵* A complete list of the Detection of Ischemia in Asymptomatic Diabetes (DIAD) Investigators can be found in the appendix.
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F.J.Th.W. has received honoraria and consulting fees from Bristol-Myers Squibb Medical Imaging and Fujisawa; has received grant/research support from Bristol-Myers Squibb Medical Imaging, Fujisawa, AstraZeneca, and Mitsubishi; and has served on advisory boards for AstraZeneca and Mitsubishi. L.H.Y., D.A.C., J.A.D., and S.D.W. have received grant/research support from Bristol-Myers Squibb Medical Imaging and Fujisawa. S.E.I. has received honoraria and grant/research support from Bristol-Myers Squibb Medical Imaging. R.T. holds stock in and has received grant/research support from Bristol-Myers Squibb Medical Imaging. S.E. has received grant/research support from Bristol-Myers Squibb Medical Imaging. R.E.R. holds stock in and has received grant/research support from Bristol-Myers Squibb Medical Imaging. A.E.I. has received honoraria from Fujisawa and grant/research support from CV Therapeutics, Fujisawa, Berlex, and Amersham.
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.
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- Accepted May 5, 2004.
- Received February 9, 2004.
- DIABETES CARE
