Risk stratification and screening for coronary artery disease in asymptomatic patients with diabetes mellitus: Position paper of the French Society of Cardiology and the French-speaking Society of Diabetology

The skin autofluorescence may help to select patients with Type 2 diabetes candidates for screening to revascularization procedures

Chen et al. recently related the skin autofluorescence (SAF) of Advanced Glycation End-products to subclinical cardiovascular disease in the 3001 participants from the general population (Rotterdam study), with a particularly close relationship for the 413 subjects with diabetes. Because conventional vascular risk factors do not capture the risk in diabetes very well, this relationship may help to select high-risk individuals for the screening of silent myocardial ischemia, which has yet to prove its benefit in randomized controlled trials. Among 477 patients with uncontrolled and/or complicated Type 2 Diabetes, we measured the SAF ten years ago, and we registered new revascularizations during a 54-months follow-up. The patients with SAF > 2.6 Arbitrary units (AUs), the median population value, experienced more revascularizations of the coronary (17/24) and lower-limb arteries (13/17) than patients with a lower SAF, adjusted for age, sex, diabetes duration, vascular complications, and smoking habits: HR 2.17 (95% CI: 1.05-4.48), p = 0.035. The SAF has already been reported to predict cardiovascular events in three cohorts of people with diabetes. We suggest that its measurement may help to improve the performance of the screening before vascular explorations and revascularizations.

Distribution and determinants of coronary artery calcium score in asymptomatic patients with Type-2 diabetes: The French-CAC100 score

BACKGROUND

Coronary artery calcium score (CACS) refines the cardiovascular disease (CVD) risk prediction in patients with Type-2 diabetes (T2D). We aimed to identify the determinants for high CACS in CVD-free patients with T2D.

METHODS

We studied 796 patients with T2D with CACS measured in three centers: two in continental France and a third in the Reunion Island. To predict a CACS ≥ 100, we derived a risk score in patients in continental France, and validated it in those in the Reunion Island.

RESULTS

The distributions of CACS distributions were similar among patients in continental France and Reunion Island. The French-CAC100 score included 5 parameters (age, sex, diabetes duration, non-CV end-organ damage and presence of ≥ 2 other CVD risk factors), ranging from 0 to 22 points. Similar areas under the curves were found for the risk score in both settings (0.80 vs. 0.73, p = 0.10). A French-CAC100 score < 10 excluded the odds for CACS ≥ 100 and CACS ≥ 400 with negative predictive values of 90% and 97% respectively, avoiding 58% of CT-scans.

CONCLUSION

Regardless of the geographic area, patients with T2D share similar risk factors for high CACS. The French-CAC100 score allows the identification of those at higher risk of elevated CACS.

Cost-effectiveness of screening of coronary artery disease in patients with type 2 DIABetes at a very high cardiovascular risk (SCADIAB study) rational and design

Background

Screening for coronary artery disease (CAD) remains broadly performed in patients with type 2 diabetes (T2DM), although the lack of evidence. We conduct a real-world evidence (RWE) study to assess the risk of major clinical outcomes and economic impact of routine CAD screening in T2DM individuals at a very high cardiovascular risk.

Methods

SCADIAB is a comparative nationwide cohort study using data from the French National Health Data System. The main inclusion criteria are: age ≥ 40 years, DT2 diagnosed for ≥ 7 years, with ≥ 2 additional cardiovascular risk factors plus a history of microvascular or macrovascular disease, except CAD. We estimated ≥ 90,000 eligible participants for our study. Data will be extracted from 01/01/2008 to 31/12/2019. Eligible participants will be identified during a first 7-year selection period (2008–2015). Each participant will be assigned either in experimental (CAD screening procedure during the selection period) or control group (no CAD screening) on 01/01/2015, and followed for 5 years. The primary endpoint is the incremental cost per life year saved over 5 years in CAD screening group versus no CAD screening. The main secondary endpoints are: total 5-year direct costs of each strategy; incidence of major cardiovascular (acute coronary syndrome, hospitalization for heart failure, coronary revascularization or all-cause death), cerebrovascular (hospitalization for transient ischemic attack, stroke, or carotid revascularization) and lower-limb events (peripheral artery disease, ischemic diabetic foot, lower-limb revascularization or amputation); and the budget impact for the French Insurance system to promote the cost-effective strategy. Analyses will be adjusted for a high-dimension propensity score taking into account known and unknown confounders. SCADIAB has been funded by the French Ministry of Health and the protocol has been approved by the French ethic authorities. Data management and analyses will start in the second half of 2021.

Discussion

SCADIAB is a large and contemporary RWE study that will assess the economic and clinical impacts of routine CAD screening in T2DM people at a very high cardiovascular risk. It will also evaluate the clinical practice regarding CAD screening and help to make future recommendations and optimize the use of health care resources.

Trial registration ClinicalTrials.gov Identifier: NCT04534530 (https://clinicaltrials.gov/ct2/show/NCT04534530)