Journal Article

Screening for Coronary Artery Disease in Patients With Diabetes

Bax, Jeroen J, Bonow, Robert O, Barrett, Eugene J, Frye, Robert L, Steinberg, Helmut O, Young, Lawrence H

2007

Overview

Coronary artery disease (CAD) accounts for a large fraction of the morbidity, mortality, and cost of diabetes. Recognizing this, nearly 10 years ago the American Diabetes Association published a consensus recommendation that clinicians consider a risk factor-guided screening approach to early diagnosis of CAD in both symptomatic and asymptomatic patients. Subsequent clinical trial results have not supported those recommendations. Since the prior consensus statement, newer imaging methods, such as coronary artery calcium scoring and noninvasive angiography with 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 approach to more widespread coronary atherosclerosis screening. However, over this same time interval, there has been recognition of diabetes as a cardiovascular disease (CVD) equivalent, clear demonstration that medical interventions should provide primary and secondary CVD risk reduction in diabetic populations, and suggestive evidence that percutaneous coronary revascularization may not provide additive survival benefit to intensive medical management in patients with stable CAD. This additional evidence raises the question of whether documenting asymptomatic atherosclerosis or ischemia in people with diabetes is warranted. More data addressing this issue will be forthcoming from the BARI 2-D (Bypass Angioplasty Revascularization 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 cardiac CT as the initial test, be reserved for those in whom medical treatment goals cannot be met and for selected individuals in whom there is strong clinical suspicion of very-high-risk CAD. Better approaches to identify such individuals based on readily obtained clinical variables are sorely needed.

• Publisher: American Diabetes Association
• Subject: atherosclerosis / Atherosclerosis - epidemiology / Atherosclerosis - prevention & control / Biological and medical sciences / calcium / Cardiovascular disease / clinical trials / computed tomography / coronary artery disease / Coronary Disease / Coronary Disease - epidemiology / Coronary Disease - prevention & control / Coronary heart disease / coronary vessels / Diabetes / Diabetes. Impaired glucose tolerance / Diabetic Angiopathies / Diabetic Angiopathies - epidemiology / Diabetic Angiopathies - prevention & control / Diabetic Neuropathies / Diabetic Neuropathies - epidemiology / Diabetic Retinopathy / Diabetic Retinopathy - epidemiology / Diabetics / Diagnosis / early diagnosis / Endocrine pancreas. Apud cells (diseases) / Endocrinopathies / epidemiology / Etiopathogenesis. Screening. Investigations. Target tissue resistance / Heart attacks / Humans / Hyperglycemia / Hyperglycemia - epidemiology / image analysis / Mass Screening / Medical examination / Medical sciences / Medical screening / medical treatment / Metabolic diseases / Methods / Miscellaneous / morbidity / Mortality / noninsulin-dependent diabetes mellitus / patients / people / Periodic health examinations / Physical diagnosis / prevention & control / Public health. Hygiene / Public health. Hygiene-occupational medicine / risk / Risk Assessment / risk reduction / screening