Identification of myocardial ischemia in the diabetic patient Joint ALFEDIAM and SFC recommendations

Ambulatory 24-h ECG monitoring and cardiovascular autonomic assessment for the screening of silent myocardial ischemia in elderly type 2 diabetic hypertensive patients

The aim of the study was to evaluate the usefulness of Holter monitoring for the detection of silent myocardial ischemia (SMI) in elderly type 2 diabetic patients with hypertension and the possible relationship between SMI and cardiovascular autonomic neuropathy (CAN). Two hundred and forty-three asymptomatic outpatients, aged 65-75 years, with type 2 diabetes and essential hypertension underwent 24-h ECG monitoring and 5 tests for the evaluation of both parasympathetic (heart rate variability, response to breath deeping, and Valsalva manoeuvre) and sympathetic (cold pressor test and orthostatic hypotension test) autonomic function. A total of 518 asymptomatic episodes of ST depression during Holter monitoring indicative of SMI were detected in 51 of the 243 studied patients (20.9 %). None of the patients with ST depression episodes exhibited a normal response to at least one of the evaluated autonomic function tests, whereas 22 of the 192 patients without ST changes (11.4 %) exhibited a normal response to all tests. Abnormality in both parasympathetic and sympathetic function test responses was found in 94.1 % of patients with ST depression episodes vs 26.1 % of those without ST changes (P < 0.001). Statistical evaluation of the relationship between the abnormal response to single autonomic function test and episodes of ST depression was highly significant for all the 5 tests (P < 0.001). These results indicate that: (a) Holter monitoring enables to detect ST segment changes indicative of SMI in 20.9 % of elderly diabetic patients with hypertension; (b) the presence of autonomic cardiac dysfunction in these patients suggests a role of diabetic neuropathy in the pathogenesis of SMI; and

The Degree of Diabetic Retinopathy in Patients with Type 2 Diabetes Correlates with the Presence and Severity of Coronary Heart Disease

Both diabetic retinopathy (DR) and coronary heart disease (CHD) are clinically significant in diabetic patients. We investigated the correlation between the severity of DR and the presence and severity of CHD among type 2 diabetic patients. A total of 175 patients who were examined at the DR clinic and underwent dual-source computed tomography (DSCT) angiography within 6 months were included. The degree of DR was graded as no DR, nonproliferative DR (NPDR), and proliferative DR (PDR). The severity of CHD and the numbers of significant stenotic coronary artery on DSCT angiography according to DR grade were assessed. The mean Agatston Calcium Score (ACS) in patients with PDR was significantly higher than other groups (P < 0.001). The overall odds of an ACS increase were about 4.7-fold higher in PDR group than in no DR group (P < 0.001). In PDR group, in comparison with in no DR, the odds of having 1 or 2 arterial involvement were 3-fold higher (P = 0.044), and those of having 3 were 17-fold higher (P = 0.011). The c-index, one of the predictability values in regression analysis model, was not significantly increased when PDR was added to classical CHD risk factors (0.671 to 0.706, P = 0.111). Conclusively, patients with PDR develop a greater likelihood of not only having CHD, but being more severe nature. PDR has no additional effect to classical CHD risk factors for predicting CHD.

Holter monitoring for the screening of cardiac disease in diabetes mellitus: The non-invasive Holter monitoring observation of new cardiac events in diabetics study

We investigated the usefulness of Holter monitoring to detect cardiac disease and predict future cardiovascular risk in asymptomatic diabetic patients. This is a multi-centre, prospective study in 406 asymptomatic diabetic patients. They were categorized into three groups based on findings of Holter monitoring. A total of 377 met inclusion criteria and were classified as low (n = 172), moderate (n = 136) and high risk (n = 69). In total, 86 in moderate and 53 in high risk receive further evaluation. In total, 29 in moderate and 25 in high risk were diagnosed as cardiac disease and 12 required additional treatment, including coronary intervention. Over 1.8 years of mean follow-up, 11 (16.5 per 1000 person-years) experienced cardiovascular events. The cumulative incidence in moderate and high risk was higher than that in low risk (p = 0.029 and p = 0.014, respectively). Our study suggests that Holter monitoring may be a useful screening tool to detect cardiac disease and predict future cardiovascular risk in asymptomatic diabetic patients.

Flow-mediated-paradoxical vasoconstriction is independently associated with asymptomatic myocardial ischemia and coronary artery disease in type 2 diabetic patients

BACKGROUND

To investigate whether flow-mediated dilation (FMD) impairment, which precedes overt atherosclerosis, is associated with silent myocardial ischemia (SMI) and asymptomatic coronary artery disease (CAD) in type 2 diabetes.

METHODS

Forearm FMD was measured by ultrasonography in 25 healthy control, 30 non-diabetic overweight or obese patients and 118 asymptomatic type 2 diabetic patients with a high cardiovascular risk profile. SMI (abnormal stress myocardial scintiscan and/or stress dobutamine echocardiogram) and CAD (coronary angiography in the patients with SMI) were assessed in the diabetic cohort.

RESULTS

FMD was lower in diabetic patients (median 0.61% (upper limits of first and third quartiles -1.22;3.2)) than in healthy controls (3.95% (1.43;5.25), p < 0.01) and overweight/obese patients (4.25% (1.74;5.56), p < 0.01). SMI was present in 60 diabetic patients, including 21 subjects with CAD. FMD was lower in patients with SMI than in those without (0.12% (-2.3;1.58) vs 1.64% (0;3.69), p < 0.01), with a higher prevalence of paradoxical vasoconstriction (50.0% vs 29.3%, p < 0.05). FMD was also lower in patients with than without CAD (-1.22% (-2.5;1) vs 1.13% (-0.4;3.28), p < 0.01; paradoxical vasoconstriction 61.9% vs 34.4%, p < 0.05). Logistic regression analyses considering the parameters predicting SMI or CAD in univariate analyses with a p value <0.10 showed that paradoxical vasoconstriction (odds ratio 2.7 [95% confidence interval 1.2-5.9], p < 0.05) and nephropathy (OR 2.6 [1.2-5.7], p < 0.05) were independently associated with SMI; and only paradoxical vasoconstriction (OR 3.1 [1.2-8.2], p < 0.05) with CAD. The negative predictive value of paradoxical vasoconstriction to detect CAD was 88.7%.

CONCLUSIONS

In diabetic patients, FMD was independently associated with SMI and asymptomatic CAD.

TRIAL REGISTRATION

Trial registration number NCT00685984.

The report of male gender and retinopathy status improves the current consensus guidelines for the screening of myocardial ischemia in asymptomatic type 2 diabetic patients

BACKGROUND AND AIMS

American Diabetes Association (ADA), French-speaking Societies for diabetes & cardiology (ALFEDIAM-SFC) and Cardiac Radionuclide Imaging (CRI) have proposed guidelines for the screening of silent myocardial ischemia (SMI). The aim of the study was to evaluate their diagnostic values and how to improve them.

METHODS AND RESULTS

731 consecutive type 2 diabetic patients with ≥1 additional risk factor were screened between 1992 and 2006 for SMI by stress myocardial scintigraphy and for silent coronary artery disease (CAD) by coronary angiography. A total of 215 (29.4%) patients had SMI, and 79 of them had CAD. ADA (Odds Ratio 1.7 [95% Confidence Interval: 1.2-2.5]; p < 0.05), ALFEDIAM-SFC (OR 1.5 [1.0-2.5], p < 0.05) and CRI criteria (OR 2.0 [1.4-2.8], p < 0.01) predicted SMI. Considering the presence of male gender and retinopathy added to the prediction of SMI allowed by ADA criteria (c statistic: area under the curve AROC 0.651 [0.605-0.697] versus 0.582 [0.534-0.630]), p < 0.01 and ALFEDIAM-SFC criteria (AROC 0.672 [0.620-0.719] versus 0.620 [0.571-0.670], p < 0.05). CRI prediction of SMI was improved by considering the presence of macroproteinuria and retinopathy (AROC 0.621 [0.575-0.667] versus 0.594 [0.548-0.641], p < 0.01). Severe retinopathy (OR 3.4 [1.2-9.4], p < 0.05), smoking habits (OR 2.1 [1.1-4.2], p < 0.05) and triglyceride levels (OR 1.3 [1.0-1.6], p < 0.05) were independent predictors of CAD in the patients with SMI.

CONCLUSION

Current guidelines criteria are able to predict SMI but prediction may be improved by considering male gender and the presence of retinopathy. CAD is more frequent in the patients with SMI who are current smokers, have severe retinopathy and higher triglyceride levels.

[Type 2 diabetes in the elderly, which specific features?]

Type 2 diabetes, whose prevalence has increased among elderly aged over 75 years, has a number of specific features which differ from that in young people: heterogeneous population, association with other cardiovascular risk factors and several comorbidities, different therapeutic constraints and risks, and lower life expectancy. By using a standardized geriatric assessment it is possible to determine therapeutic and glycemic goals for each patient. In the elderly, main complications of diabetes are hypoglycemia and foot lesions. In order to avoid malnutrition, lifestyle and dietary rules should not be too strict. Recommendations for the prescription of oral antidiabetic agents are the same for both elderly and young subjects, but with increased monitoring in the elderly because of the high risk of complications including iatrogenic hypoglycemia. Insulin therapy should be preferred.

Cardiovascular risk prediction is improved by adding asymptomatic coronary status to routine risk assessment in type 2 diabetic patients

OBJECTIVE

To evaluate if silent myocardial ischemia (SMI) and silent coronary artery disease (CAD) provide significant additional value to routine cardiovascular risk assessment in type 2 diabetic patients.

RESEARCH DESIGN AND METHODS

We followed up to a first cardiovascular event 688 subjects (322 men, aged 59 ± 8 years) out of 731 consecutive asymptomatic type 2 diabetic patients with ≥1 additional risk factor who had been prospectively screened between 1992 and 2006 for SMI by stress myocardial scintigraphy and for silent CAD by coronary angiography.

RESULTS

SMI was found in 207 (30.1%) patients and CAD in 76 of those with SMI. Of the patients, 98 had a first cardiovascular event during a 5.4 ± 3.5 (range: 0.1-19.2) year follow-up period. Cox regression analysis considering parameters predicting events but not SMI and CAD ("routine assessment") showed in univariate analyses that macroproteinuria (hazard ratio [HR] 3.33 [95% CI 1.74-6.35]; P < 0.001), current multifactorial care (0.27 [0.15-0.47]; P < 0.001), and peripheral/carotid occlusive arterial disease (PCOAD; 4.33 [2.15-8.71]; P < 0.001) independently predicted cardiovascular events. When added into the model, SMI (HR 1.76 [1.00-3.12]; P = 0.05) and CAD (2.28 [1.24-4.57]; P < 0.01) were also independently associated with events. SMI added to the prediction of an event in the following 5 years above and beyond routine assessment risk prediction (c statistic with or without SMI 0.788 [0.720-0.855] and 0.705 [0.616-0.794], respectively).

CONCLUSIONS

Although screening for SMI and silent CAD should not be systematic, these complications are predictive of cardiovascular events in type 2 diabetic patients in addition to routine risk predictors, especially represented by PCOAD, macroproteinuria, and nonintensive management.

Myocardial ischemia: a silent epidemic in Type 2 diabetes patients

The prevalence of diabetes mellitus is increasing consistently. Coronary artery disease (CAD) is the main cause of death; however, silent myocardial ischemia (SMI) is more frequent in diabetic patients. Early CAD diagnosis provided by SMI screening could lead to decreased cardiovascular complications and mortality. Current guidelines recommend screening for SMI in asymptomatic diabetic patients selected on a basis of high cardiovascular risk, followed by coronary angiogram in case of a positive stress test. However, the benefit of systematic SMI screening has not been demonstrated in diabetic patients with optimal treatment of risk factors. The benefit of revascularization in diabetic patients with SMI seems to be restricted to patients with severe CAD. Prospective studies are required to identify diabetic patients who may potentially benefit from SMI screening. These patients should have a high prevalence of severe CAD and potential benefit of revascularization, such as patients with renal failure, left ventricular dysfunction and peripheral or carotid occlusive arterial disease.

[Screening of silent myocardial ischemia in diabetic patients: Practical details and issues]

Silent myocardial ischemia is more frequent in diabetic patients. Nevertheless, its prevalence depends on global cardiovascular risk. Although this is a factor of overmortality, its screening is discussed. In fact, crucial issue is the demonstration of a benefit from revascularizing immediately any coronary stenosis in silent diabetic patients. Recent studies report no benefit of revascularization by endovascular treatment versus medical treatment in patients with stable coronary disease in general population and in diabetic patients. Screening of silent myocardial ischemia should be only proposed to diabetic patients with a very high probability of multivessel disease. Only these patients could benefit from surgical revascularization. For the other diabetic patients, it seems to be reasonable that only patients with cardiovascular risk factors not controlled by medical treatment should benefit from screening, whose optimal practical details stay discussed.

[Perioperative management of diabetic patient]

The prevalence of diabetes is rising and diabetics may soon represent more than 5% of the world population. The type 2 diabetes is a major independent risk factor for coronary artery disease. The screening for silent myocardial ischemia (IMS) must be systematic. The autonomic dysfunction and the cardiac microcirculatory disorders are at risk of hypotension and hypothermia during anesthesia. After 10 years of diabetes duration the incidence of perioperative complications and of difficult intubation are increased. The neurological deficits related to anesthesia are associated with general anesthesia in 85% of cases. Particular care will be provided during the surgical procedure to avoid skin, muscular and neurologic cuts. In most cases, the regional anesthesia will be preferred to general anesthesia. To avoid hypoglycemia, blood glucose concentration less than 11 mmol.L(-1)(2g.L(-1)) seems a reasonable target during and after surgery.

Detection of silent myocardial ischemia in asymptomatic patients with diabetes: results of a randomized trial and meta-analysis assessing the effectiveness of systematic screening

BACKGROUND

Most guidelines recommend a systematic screening of asymptomatic high risk patients with diabetes for silent ischemia, but the clinical benefit of this strategy has not been demonstrated compared with the simple control of cardiovascular risk factors. We sought to determine whether referring asymptomatic diabetic patients for screening of silent ischemia decreases the risk of cardiovascular events compared with usual care.

METHODS

DYNAMIT was a prospective, randomized, open, blinded end-point multicenter trial run between 2000 and 2005, with a 3.5 year mean follow-up in ambulatory care in 45 French hospitals. The study included 631 male and female with diabetes aged 63.9 ± 5.1 years, with no evidence of coronary artery disease and at least 2 additional cardiovascular risk factors, receiving appropriate medical treatment. The patients were randomized centrally to either screening for silent ischemia using a bicycle exercise test or Dipyridamole Single Photon Emission Computed Tomography (N = 316), or follow-up without screening (N = 315). The main study end point was time to death from all causes, non-fatal myocardial infarction, non-fatal stroke, or heart failure requiring hospitalization or emergency service intervention. The results of a meta-analysis of DYNAMIT and DIAD, a similar study, are also presented.

RESULTS

The study was discontinued prematurely because of difficulties in recruitment and a lower-than expected event rate. Follow-up was complete for 98.9% patients regarding mortality and for 97.5% regarding the main study end point. Silent ischemia detection procedure was positive or uncertain in 68 (21.5%) patients of the screening group. There was no significant difference between the screening and the usual care group for the main outcome (hazard ratio = 1.00 95%CI 0.59 to 1.71). The meta-analysis of these and DIAD results gave similar results, with narrower confidence intervals for each endpoint.

CONCLUSIONS

These results suggest that the systematic detection of silent ischemia in high-risk asymptomatic patients with diabetes is unlikely to provide any major benefit on hard outcomes in patients whose cardiovascular risk is controlled by an optimal medical treatment.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00627783.

Five-year outcomes in high-risk participants in the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study: a post hoc analysis

OBJECTIVE

To estimate baseline cardiovascular risk of 1,123 participants in the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study and to assess cardiac event rates and the effect of screening on outcomes in these higher-risk participants.

RESEARCH DESIGN AND METHODS

Baseline cardiovascular risk was assessed using four established methods: Framingham score, UK Prospective Diabetes Study (UKPDS) risk engine, criteria of the French-Speaking Association for the Study of Diabetes and Metabolic Diseases, and the presence or absence of metabolic syndrome. Cardiac events (cardiac death or nonfatal myocardial infarction) were assessed during the 4.8-year follow-up in participants with intermediate/high cardiovascular risk.

RESULTS

By various risk-stratification approaches, 53-75% of participants were defined as having intermediate or high cardiovascular risk. The prevalence of inducible ischemia on screening in these individuals ranged from 21 to 24%, similar to lower-risk participants (19-23%). Cardiac event rates were greater in intermediate-/high-risk versus low-risk groups, but this was only significant for the UKPDS risk engine (4.2 vs. 1.2%, P = 0.002). The annual cardiac event rate was <1% in all risk groups, except in the high-risk UKPDS group (∼2% per year). In intermediate-/high-risk participants randomized to screening versus no screening, 4.8-year cardiac event rates were similar (2.5-4.8% vs. 3.1-3.7%).

CONCLUSIONS

A substantial portion of the DIAD population was defined as having intermediate/high baseline cardiovascular risk. Nevertheless, their annual cardiac event rate was low and not altered by routine screening for inducible ischemia.

Carotenoid deficiency in chronic pancreatitis: the effect of an increase in tomato consumption

BACKGROUND/OBJECTIVES

Carotenoids are potentially malabsorbed in patients with chronic pancreatitis (CP). The aims of this study were: (1) to determine the prevalence of low levels of each of the major carotenoids in subjects with CP; (2) to compare carotenoids in CP subjects with or without vascular disease and (3) to test the effect of an increase in dietary lycopene intake in patients with low plasma lycopene concentration.

SUBJECTS/METHODS

Simultaneous determination of carotenoids was done in 80 patients with CP and 20 healthy subjects, using high-performance liquid chromatography. Of the CP patients who had low lycopene concentration, 22 (<120 μg/l) had to consume daily 40 g tomato paste (approximately 24 mg lycopene).

RESULTS

Of these patients, 84.7% had at least one carotenoid deficiency and 27.5% had more than four carotenoid deficiencies. Low plasma concentrations in β-carotene and lycopene were correlated, in CP group, with a low body mass index (BMI), a low low-density lipoprotein (LDL) cholesterol concentration, alcohol consumption and current smoking status, whereas low plasma concentration in β-cryptoxanthine was correlated with a low BMI, a low LDL cholesterol concentration and alcohol consumption. Lycopene concentration was decreased in patients with vascular disease (171±197 vs 99±72 μg/l; P=0.02). After an intervention period of 8±2 months, lycopene concentration increased from 67.5±30 to 121.8±102 μg/l (P=0.025).

CONCLUSION

Carotenoid concentrations are dramatically decreased in CP, especially lycopene in CP patients with vascular disease. Despite malabsorption, it is possible to increase lycopene plasma concentration by increasing heated tomato consumption.

Myocardial perfusion scintigraphy in asymptomatic diabetic patients: a critical review

The increasing prevalence of diabetes mellitus and the associated high cardiovascular risk has made the non-invasive identification of silent coronary heart disease in diabetic individuals an important issue. This strategy could identify higher risk asymptomatic patients with diabetes mellitus in whom coronary revascularization may improve the outcome beyond that achieved by currently recommended medical management. Stress myocardial perfusion imaging has been shown to be effective in detecting coronary heart disease and predicting adverse cardiac events in asymptomatic diabetic patients. However, the clinical utility of myocardial perfusion scintigraphy is debated intensively due to the paucity of prospective and outcome based evidence. The controversy stems from several observational studies, epidemiologic data and cost-effectiveness analyses. Thus, although several authors and professional organizations advocate the use of stress imaging for screening higher risk asymptomatic diabetic patients, others are cautious in recommending any kind of stress testing in that population. This review is based on a broad survey of the literature and discusses the potential role of stress myocardial perfusion scintigraphy in screening asymptomatic diabetic subjects for coronary heart disease in the current era and in relation with other non-invasive screening tools.

N-terminal pro-B-type natriuretic peptide: an independent marker for coronary artery disease in asymptomatic diabetic patients

AIMS

To determine whether plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, a marker for cardiac failure and potentially for the severity of coronary artery disease (CAD), predicts silent myocardial ischaemia (SMI) and silent CAD in asymptomatic high-risk diabetic patients.

METHODS

Five hundred and seventeen asymptomatic diabetic patients with > or = 1 additional cardiovascular risk factor but without heart failure were prospectively screened between 1998 and 2008 for SMI, defined as an abnormal stress myocardial scintigraphy, and subsequently for significant (> 70%) angiographic CAD. The 323 patients with interpretable echocardiography and for whom NT-proBNP was measured were included in this analysis.

RESULTS

SMI was found in 108 (33.4%) patients, 39 of whom had CAD. NT-proBNP was higher in the patients with CAD than in the patients without CAD [45.0 (1-3199) vs. 20.0 (1-1640) pg/ml; P < 0.0001 median (range)], even after adjustment for confounding factors: age, gender, body mass index, glycated haemoglobin (HbA(1c)), retinopathy, nephropathy, hypertension, echocardiographic parameters (P < 0.05). NT-proBNP in the third tertile (> or = 38 pg/ml) predicted CAD with a sensitivity of 59% and a specificity of 67%. In a multiple logistic regression analysis including NT-proBNP > or = 38 pg/ml, age, body mass index, gender, HbA(1c), hypertension, retinopathy, nephropathy, peripheral occlusive arterial disease, left ventricular systolic dysfunction, dilatation and hypertrophy and Type 1 transmitral flow, NT-proBNP > or = 38 pg/ml was the only significant independent predictor of silent CAD [odds ratio (OR) 3.1 (95% confidence interval 1.3-7.6), P = 0.015].

CONCLUSIONS

NT-proBNP measurement helps to better define asymptomatic diabetic patients with an increased likelihood for CAD, independently of cardiac function and structure.

Silent myocardial ischemia screening in patients with diabetes mellitus

The prevalence of diabetes mellitus is fairly increasing, especially in the developing countries. Diabetes is a major cardiovascular risk factor; it often leads to severe cardiovascular complications, and coronary artery disease (CAD) is the main cause of death in diabetic patients. Silent myocardial ischemia (SMI) is more frequent in diabetic patients. The progress made in detection and treatment of CAD allows reconsidering the screening of SMI, in the hope that early CAD diagnosis leads to a more effective therapy and the decrease of cardiovascular complications and mortality. However, the benefit of systematic SMI screening remains discussed. Current guidelines recommend screening SMI in asymptomatic diabetic patients selected for high cardiovascular risk (i.e. with two or more other cardiovascular risk factors, or peripheral or carotid arterial disease, or proteinuria). ECG stress test can be recommended in first intention if maximal heart rate can be achieved. For patient with inconclusive ECG stress test, myocardial scintigraphy seems more accurate than stress echocardiography. Coronary angiogram should be performed in case of positive stress test. Further evaluations of systematic screening have to be conducted on broad randomized trial.

[Cardiovascular assessment of diabetic patients]

INTRODUCTION

Type 2 diabetes is a cardiovascular disease. The morbidity and mortality among these patients are primarily due to cardiovascular diseases. There are many guidelines regarding clinical evaluation of cardiovascular disease in those patients. Implementation of these guidelines has been an argued subject. Our objective in this paper is to describe what basal cardiovascular evaluation has been carried out at a specialized university Diabetes Center.

SUBJECTS AND METHODS

Data were collected from February to October 2006 of 121 type 2 diabetes individuals who were enrolled at the Diabetes Center of Federal University of São Paulo. We analyzed the type of cardiovascular disease evaluation that they had been submitted in the year that preceded the consultation.

RESULTS

We have observed a high prevalence of several other cardiovascular risk factors in this population. The cardiovascular evaluations during this period has shown 36% of the patients had not been submitted to any cardiovascular test, 17% had been submitted to resting electrocardiogram and 27% of the patients had been submitted to exercise test. Rest echocardiogram, pharmacologic stress echocardiogram, myocardial perfusion scintigraphy, and coronary angiography have been carried out in a much lesser ratio.

CONCLUSION

Our data has shown the variability and limitations on boarding diagnosing of DAC in university environment patients and point us the necessity of constructing defined and directed directives for the peculiarities of the Brazilian population and health system.

Coronary heart disease and cardiovascular autonomic neuropathy in the elderly diabetic

Diabetes and old age come together to increase the frequency and severity of coronary heart disease. Often clinically nearly silent, symptoms frequently manifest dramatically, to such an extent that the question of screening should be raised, as in younger subjects. Preventing these manifestations relies on better management of the cardiovascular risk factors and obtaining good blood glucose control, but here progress remains necessary, which also requires adapting to the older patient's clinical and psychological condition. Cardiovascular autonomic neuropathy is a frequent degenerative complication in diabetics, particularly in the oldest subjects. The most severe types have serious clinical consequences, thus a higher mortality factor, but the mechanisms remain poorly understood. As for coronary heart disease, the therapeutic tools have expanded these last few years and should be thought out in relation to the geriatric evaluation, with the objective of improving these patients' quality of life. Therefore, a necessary distinction should be made between subjects who have aged successfully, whose management, ultimately, differs little from younger subjects, and frail elderly individuals for whom exploratory techniques and treatment should be adapted.

When should ultrasonography be used to detect asymptomatic carotid atheroma in diabetic patients?

INTRODUCTION

While guidelines for detection of silent myocardial and lower limb ischemia are established, data on screening asymptomatic carotid lesions remain scarce. However, such screening would be costly. Since the prevalence of diabetes increases constantly, it is necessary to keep screening costs low by setting up criteria for the selection of patients at risk of ischemic cerebral attack and those who will need medical or surgical attention. Diabetic patients, particularly type 2, often have many reasons to take anti-platelet agents and lipid-lowering therapy. Therefore, carotid ultrasonography screening would have little effect on treatment modification or on glycaemia and blood pressure objectives, but could improve the prognosis of operable lesions.

IN THE GENERAL POPULATION

A one-time screening program was considered worthwhile if the prevalence of severe asymptomatic stenosis was over 20%. The presence of another arterial occlusive disease or other cardio-vascular risk factors could be a major argument for screening.

IN DIABETIC PATIENTS

Carotid intima-media thickness (IMT) was recognized as a reliable prognostic indicator of heart attack and stroke. It worsens with duration of diabetes, renal failure, cardiac neuropathy and poor long term glycaemic control.

CONCLUSION

Our review suggests that a one-time carotid ultrasonography screening could be recommended for diabetic patients with coronary disease or lower limb atherosclerosis (secondary prevention), all diabetic patients above 60 years of age, smokers, hypertensive and with hypercholesterolemia; type 1 diabetic patients with poor long term glycaemic control; all type 2 diabetic patients with renal failure, a long duration of ill-controlled diabetes or with a carotid bruit. This literature review should be analyzed with caution. It would be helpful to organize a prospective long term study on all types of diabetic patients, including a carotid ultrasonography screening program by experienced radiologists.

Six-year follow-up of a cohort of 203 patients with diabetes after screening for silent myocardial ischaemia

AIMS

To determine the prognosis of patients with Type 1 or Type 2 diabetes, 6 years after screening for silent myocardial ischaemia (SMI).

METHODS

Two hundred and three asymptomatic patients with diabetes underwent systematic SMI screening. From the results of this screening, they were allocated to one of three groups: patients (n = 171) with negative screening; patients (n = 32) with positive screening; and patients (n = 21) with positive screening and coronary stenosis. Six years after the initial assessment, all patients were re-assessed. All events [death, cardiac death, non-fatal major cardiac events (NFMCEs)--acute myocardial infarction, ventricular rhythm disorders, heart failure, unstable angina] were recorded.

RESULTS

Fifteen patients were lost to follow-up. Patients (n = 20) with positive SMI screening and coronary stenosis had a higher risk of NFMCEs (35% vs. 7%, P < 0.001), and a higher mortality rate (35% vs. 15%, P < 0.05) compared with patients (n = 157) with negative screening. SMI-positive patients (n = 31) had a higher NFMCE rate compared with negative SMI screening patients, although overall mortality rate was no different. Cancer was the leading cause of death (36.4%). In multivariate analysis, major cardiac events (cardiac death and NFMCE) were related to baseline age, body mass index and coronary stenosis (P < 0.01).

CONCLUSIONS

Patients with diabetes and SMI have a very poor prognosis as assessed by cardiac events or death, especially in the presence of coronary stenosis.

Prevalence of silent myocardial ischaemia in new-onset middle-aged Type 2 diabetic patients without other cardiovascular risk factors

AIMS

Coronary artery disease (CAD) is the leading cause of death in patients with Type 2 diabetes and is often asymptomatic. Silent myocardial ischaemia (SMI) is frequent in diabetic subjects and is responsible for a late diagnosis of CAD; its early detection is important. There are some data about the prevalence of SMI in Type 2 diabetic patients at high risk for cardiovascular disease, while no data are available in subjects at the onset of diabetes without other cardiovascular risk factors.

METHODS

We screened 274 consecutive patients (mean age 64.3 +/- 8.4 years, 66% male) at the time of diagnosis of Type 2 diabetes; we enrolled 111 subjects without other cardiovascular disease risk factors (dyslipidaemia, hypertension, peripheral vascular disease, retinopathy, microalbuminuria, history of heart disease) and with normal resting electrocardiogram (ECG). Participants performed a maximal ECG exercise protocol and, if positive, underwent coronary angiography.

RESULTS

The ECG exercise test was positive in 19 patients (17.1%); of those 14 (13%) had angiographic coronary disease (one with three-vessel disease, three with two vessels and 10 with one vessel involved). The positive predictive value of the exercise ECG for predicting angiographic coronary disease was 73%.

CONCLUSIONS

The prevalence of SMI was 17% and angiographic coronary disease was found in 13% of middle-aged subjects with new-onset Type 2 diabetes without other cardiovascular risk factors. This prevalence is similar to that observed in studies of subjects with long duration diabetes who have additional cardiovascular risk factors.

Predictive value of silent myocardial ischemia for cardiac events in diabetic patients: influence of age in a French multicenter study

OBJECTIVE

Silent myocardial ischemia (SMI) in asymptomatic subjects with no history of myocardial infarction or angina is a frequent condition in diabetic patients. The aim of the study was to examine the predictive value of SMI for cardiac events in a multicenter cohort and to determine whether this value is higher in patients with a particular clinical profile.

RESEARCH DESIGN AND METHODS

A total of 370 asymptomatic diabetic patients with at least two additional cardiovascular risk factors was recruited in four departments of diabetology. SMI was assessed by either exercise or dipyridamole single-photon emission-computed tomography myocardial perfusion imaging with thallium-201. If dipyridamole stress was used, an electrocardiogram stress test was performed separately on another day. Follow-up duration was 3-89 months (38 +/- 23 months).

RESULTS

There was evidence of SMI in 131 patients (35.4%) on at least one positive noninvasive test. The patients with SMI were significantly older and had significantly higher serum triglycerides and lower HDL cholesterol levels. Cardiac events occurred in 53 patients (14.3%). Major cardiac events (death or myocardial infarction) occurred in 38 patients (10%) and other events (unstable angina, heart failure, or coronary revascularization) occurred in 15 patients. The patients who had cardiac events were older and had higher serum triglyceride levels at baseline. There was a significant association between SMI and cardiac events (hazard ratio 2.79 [95% CI 1.54-5.04]) and in particular major cardiac events (3 [1.53-5.87]). In the patients >60 years of age, the prevalence of SMI was higher (43.4 vs. 30.2% in those <60 years). SMI was associated with a significant risk of cardiac events (2.89 [1.31-6.39]) and in particular major cardiac events (3.66 [1.36-9.87]) for the patients >60 years old but not for those <60 years old.

CONCLUSIONS

In asymptomatic diabetic patients with additional cardiovascular risk factors, SMI is a potent predictor of cardiac events and should be assessed preferably in the patients >60 years of age.

Prévention primaire cardio-rénale chez le diabétique de type 2

The incidence of type-2 diabetes is increasing throughout the world. By 2010, 350 million people will have this disease. Microalbuminuria is present in more than one third, for some at diabetes diagnosis. Rather than a complication, it is an indication of a vascular disorder that is part of the metabolic syndrome. 25% will develop end-stage kidney failure. Several studies have identified microalbuminuria or proteinuria as an independent cardiovascular risk factor. Others have shown that antihypertensive treatments acting on the renin-angiotensin system (ACE inhibitors, ARBs agents) can reduce the progression of nephropathy in people with hypertension, type 2 diabetes and microalbuminuria. The "nephroprotective" effects of these drug classes, beyond their role in blood-pressure reduction, are suggested by modifications in renal structure and protein expression. But no study has so far examined their value in primary prevention in persons with type 2 diabetes without--but at risk of developing--microalbuminuria. The Roadmap study (Randomized Olmesartan And Diabetes Microalbuminuria Prevention Study) of primary prevention has as its objective measurement of the impact of ARBs (olmesartan 40 mg/d) treatment on renal outcome in 4400 patients with type 2 diabetes without microalbuminuria. Follow-up of this placebo-controlled study will last for 5 years. Conducted in 200 European centers, its results are expected for 2012.