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

Precision prognostics for cardiovascular disease in Type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with Type 2 diabetes (T2D).

METHODS

We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies.

RESULTS

Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort.

CONCLUSIONS

Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Silent myocardial infarction fatty scars detected by coronary calcium score CT scan in diabetic patients without history of coronary heart disease

OBJECTIVES

To evaluate the prevalence of intra-myocardial fatty scars (IMFS) most likely indicating previous silent myocardial infarction (SMI), as detected on coronary artery calcium (CAC) computed tomography (CT) scans in diabetic patients without history of coronary heart disease (CHD).

METHODS

Diabetic patients screened for silent coronary insufficiency in a tertiary-care, university hospital between Jan-2015 and Dec-2016 were categorized according to their CAC score in two groups comprising 242 patients with CACS = 0 and 145 patients with CACS ≥ 300. CAC-CT scans were retrospectively evaluated for subendorcardial and transmural IMFS of the left ventricle. Adipose remodeling, patients' characteristics, cardiovascular risk factors and metabolic profile were compared between groups.

RESULTS

Eighty-three (21%) patients with IMFS were identified, 55 (37.9%) in the group CACS ≥ 300 and 28 (11.6%) in the CACS = 0 (OR = 4.67; 95% CI = 2.78-7.84; p < 0.001). Total and average surface of IMFS and their number per patient were similar in both groups (p = 0.55; p = 0.29; p = 0.61, respectively). In the group CACS ≥ 300, patients with IMFS were older (p = 0.03) and had longer-lasting diabetes (p = 0.04). Patients with IMFS were older and had longer history of diabetes, reduced glomerular filtration rate, more coronary calcifications (all p < 0.05), and higher prevalence of carotid plaques (OR = 3.03; 95% CI = 1.43-6.39, p = 0.004). After correction for other variables, only a CACS ≥ 300 (OR = 5.12; 95% CI = 2.66-9.85; p < 0.001) was associated with an increased risk of having IMFS.

CONCLUSIONS

In diabetic patients without known CHD, IMFSs were found in patients without coronary calcifications, although not as frequently as in patients with heavily calcified coronary arteries. It remains to be established if this marker translates in an upwards cardiovascular risk restratification especially in diabetic patients with CACS = 0.

CLINICAL RELEVANCE STATEMENT

In diabetic patients without history of coronary heart disease, intramyocardial fatty scars, presumably of post-infarction origin, can be detected on coronary artery calcium CT scans more frequently, but not exclusively, if the coronary arteries are heavily calcified as compared to those without calcifications.

KEY POINTS

• Intramyocardial fatty scars (IMFS), presumably of post-infarction origin, can be detected on coronary artery calcium (CAC) CT scans more frequently, but not exclusively, in diabetic patients with CACS ≥ 300 as compared to patients CACS = 0. • Patients with IMFS were older and had longer history of diabetes, reduced glomerular filtration rate, and more coronary calcifications. • Carotid plaques and CACS ≥ 300 were associated with an increased risk of having IMFS, about three and five folds respectively.

Precision Prognostics for Cardiovascular Disease in Type 2 Diabetes: A Systematic Review and Meta-analysis

Background Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with type 2 diabetes (T2D). Methods We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies. Results Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort. Conclusions Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Performance of the 2019 ESC/EASD guideline strategy for the screening of silent coronary artery disease in patients with diabetes

BACKGROUND

The 2019 guidelines for cardiovascular risk stratification by the European Society of Cardiology and European Association for the Study of Diabetes (ESC-EASD) suggested screening for silent coronary disease in very high risk patients with severe target organ damage (TOD) (i.e. peripheral occlusive arterial disease or severe nephropathy) or high coronary artery calcium (CAC) score. This study aimed to test the validity of this strategy.

METHODS

In this retrospective study, we included 385 asymptomatic patients with diabetes and no history of coronary disease but with TOD or ≥ 3 risk factors in addition to diabetes. CAC score was measured using computed tomography scan and a stress myocardial scintigraphy was performed to detect silent myocardial ischemia (SMI), with subsequent coronary angiography in those with SMI. Various strategies to select patients to be screened for SMI were tested.

RESULTS

CAC score was ≥ 100 Agatston units (AU) in 175 patients (45.5%). SMI was present in 39 patients (10.1%) and among the 30 patients who underwent angiography, 15 had coronary stenoses and 12 had a revascularization procedure. The most effective strategy consisted in performing myocardial scintigraphy in the 146 patients with severe TOD and, among the 239 other patients without severe TOD, in those with CAC ≥ 100 AU: this strategy provided 82% sensitivity for SMI diagnosis, and identified all the patients with stenoses.

CONCLUSION

The ESC-EASD guidelines suggesting SMI screening in asymptomatic patients with very high risk assessed by severe TOD or high CAC score appears effective and could identify all the patients with stenoses eligible for revascularization.

Clinical relevance of coronary risk classification and reclassification with coronary artery calcium score in asymptomatic people living with diabetes. An observational study

AIMS

To explore (i) in what proportion and direction coronary artery calcium (CAC) score reclassifies coronary risk in asymptomatic diabetic patients at high a priori coronary risk, and (ii) whether screening for asymptomatic myocardial ischemia / coronary stenosis only in patients at very high coronary risk - whether a priori or combined with those reclassified at very high risk according to their CAC score - has good sensitivity to detect these conditions.

METHODS

We retrospectively selected 377 asymptomatic primary prevention diabetic patients at high or very high a priori coronary risk according to national guidelines. All had their CAC score measured and underwent stress myocardial scintigraphy to detect myocardial ischemia. Those identified with ischemia then had a coronary angiography to identify coronary stenoses.

RESULTS

Of the selected patients, 242 and 135 patients had a high and very high a priori coronary risk, respectively. After taking into account their CAC score, the former were reclassified into three risk categories: moderate (n = 159, 66%), high (n = 38) and very high (45 patients) risk. Myocardial ischemia was identified in 35 patients and coronary stenoses in 14 of the latter. Had a stress scintigraphy been performed only in the 135 patients at very high risk a priori, 18 patients would have been detected with ischemia (sensitivity 51%), and 9 with coronary stenoses (sensitivity 64%). Had a scintigraphy also been performed on the 45 patients at very high risk after CAC-reclassification, an additional 7 and 5 patients with ischemia and coronary stenoses, respectively, would have been identified.

CONCLUSION

Following national guidelines, 66% of our population of asymptomatic diabetic persons at high a priori coronary risk were reclassified into the moderate risk category, translating into less stringent goals for risk factor control. Eighteen percent were reclassified into the very high-risk category, leading to 100% detection sensitivity for patients with ischemia and coronary stenoses.

Current management and screening of peripheral and coronary artery disease in people with diabetes mellitus in Europe. The PADDIA/CADDIA survey

AIMS

This survey aimed to evaluate the current management and screening of coronary artery disease and peripheral artery disease in people with type 2 diabetes mellitus (T2DM) in Europe, utilizing the 2013 ESC/EASD (European Society of Cardiology/European Association for the Study of Diabetes) guidelines as a benchmark.

METHODS

The PADDIA/CADDIA survey is a European medical research collaboration targeting cardiologists, vascular physicians, diabetologists and general practitioners from Austria, Belgium, France, Germany, Italy, Netherlands and United Kingdom.

RESULTS

The questionnaire was completed by sixty-three physicians, of whom 75% declared assessing the cardiovascular risk of people with T2DM mostly without using a risk score (59%). More than 90% of the panel, check HbA1c, blood pressure and low-density lipoprotein cholesterol targets in their patients with T2DM and coronary or peripheral artery disease. For 94% the presence of T2DM influence their patients' management, by optimizing blood glucose, blood pressure and low-density lipoprotein cholesterol control. Only 37% considered screening for lower extremity peripheral artery disease among their T2DM patients and 35% among those with cardiovascular disease.

CONCLUSIONS

Physicians mostly follow the ESC/EASD 2013 guidelines, but when it comes to screening for additional conditions including coronary artery disease or peripheral artery disease, or intensifying the antithrombotic regimen there is need for better guidance.

Epicardial adipose tissue volume and myocardial ischemia in asymptomatic people living with diabetes: a cross-sectional study

Background

Epicardial adipose tissue (EAT) is considered a novel diagnostic marker for cardiometabolic disease. This study aimed to evaluate whether EAT volume was associated with stress-induced myocardial ischemia in asymptomatic people living with diabetes—independently of confounding factors—and whether it could predict this condition.

Methods

We included asymptomatic patients with diabetes and no coronary history, who had undergone both a stress a myocardial scintigraphy to diagnose myocardial ischemia, and a computed tomography to measure their coronary artery calcium (CAC) score. EAT volume was retrospectively measured from computed tomography imaging. Determinants of EAT volume and asymptomatic myocardial ischemia were evaluated.

Results

The study population comprised 274 individuals, including 153 men. Mean (± standard deviation) age was 62 ± 9 years, and 243, 23 and 8 had type 2, type 1, or another type of diabetes, respectively. Mean body mass index was 30 ± 6 kg/m², and mean EAT volume 96 ± 36 cm³. Myocardial ischemia was detected in 32 patients (11.7%). EAT volume was positively correlated with age, body mass index and triglyceridemia, but negatively correlated with HbA1c, HDL- and LDL-cholesterol levels. Furthermore, EAT volume was lower in people with retinopathy, but higher in men, in current smokers, in patients with nephropathy, those with a CAC score > 100 Agatston units, and finally in individuals with myocardial ischemia (110 ± 37 cm³ vs 94 ± 37 cm³ in those without myocardial ischemia, p < 0.05). The association between EAT volume and myocardial ischemia remained significant after adjustment for gender, diabetes duration, peripheral macrovascular disease and CAC score. We also found that area under the ROC curve analysis showed that EAT volume (AROC: 0.771 [95% confidence interval 0.683–0.858]) did not provide improved discrimination of myocardial ischemia over the following classic factors: gender, diabetes duration, peripheral macrovascular disease, retinopathy, nephropathy, smoking, atherogenic dyslipidemia, and CAC score (AROC 0.773 [0.683–0.862]).

Conclusions

EAT may play a role in coronary atherosclerosis and coronary circulation in patients with diabetes. However, considering EAT volume is not a better marker for discriminating the risk of asymptomatic myocardial ischemia than classic clinical data.

Legacy effect of intensive glucose control on major adverse cardiovascular outcome: Systematic review and meta-analyses of trials according to different scenarios

BACKGROUND

Early and intensive glycaemic control provides long-term protection against the development of microvascular complications, a phenomenon defined legacy effect. Whether a legacy effect of high glucose exists also on macrovascular endpoints is uncertain.

METHODS AND FINDINGS

We performed a systematic review of both randomized clinical trials (RCT)s and observational studies pertinent to the research question. We searched PubMed, Embase, Scopus and the Cochrane database up to January 31th 2020. Eligibility criteria for RCTs were: 1 - efficacy assessment of intensive glucose lowering treatment vs a less-stringent/conventional treatment; 2 - the inclusion of a post-active phase, observational follow-up; 3 - enrolment of patients with T1DM, pre-diabetes, and T2DM; and 4 - data report on major adverse cardiovascular events (MACE) incidence, which was the primary endpoint of this meta-analysis. We performed multiple meta-analyses of the available RCTs according to different scenarios considering the type of diabetes, diabetes duration, the presence of previous cardiovascular events, follow-up extension, and the incidence of MACE recorded only during the observational, post-active phase of the trials. Results from observational studies reporting the association between HbA1c levels during the first year after diabetes diagnosis and subsequent MACE incidence were also collected and are reported narratively. We included data from 7 RCTs and 40,346 patients. The intensive glucose-lowering approach significantly decrease the incidence of MACE compared with conventional treatment (OR 0.86, CI 0.77-0.96; p = 0.007) when considering all the available studies, with a more consistent effect (OR 0.73, CI 0.56-0.94; p = 0.01) in the case of RCTs enrolling patients with diabetes duration <10 years, and an even more pronounced protection (OR 0.64, 48 CI 0.48, 0.86; p = 0.003) when analysing only RCTs enrolling patients without previous cardiovascular events at baseline. Considering only RCTs with a post-trial follow-up >10 years also yielded a relevant beneficial effect of the intensive approach (OR 0.71, CI 0.57, 0.88; p = 0.002). On the other hand, no effect was observed (OR 0.99, CI 0.92, 1.06; p = 0.81) when considering only the events recorded during the post-active, observational phases of the trials. Observational studies showed that HbA1c values >6.5% or 7% during the first year of diabetes diagnosis are associated with a higher incidence of late MACE with increased risk ranging from 19 up to 64%, according to the different study design and HbA1c stratification.

CONCLUSIONS

These results support the recommendation regarding glucose-lowering treatment intensification in order to decrease the probability of having a macrovascular event in patients with short diabetes duration, no prevalent cardiovascular diseases, and long life-expectancy. On the other side, data from RCTs do not support the existence of a protective legacy effect on the macrovasculature beyond the period of intensive glycaemic treatment.

Practical cardiovascular risk calculator for asymptomatic patients with type 2 diabetes mellitus: PRECISE-DM risk score

BACKGROUND

Obstructive coronary artery disease (OCAD) is a significant predictor of adverse clinical events in asymptomatic patients with type 2 diabetes mellitus (T2DM).

HYPOTHESIS

We sought to develop an easy-to-use risk scoring system to predict OCAD and long-term clinical outcome in asymptomatic patients with T2DM (PRECISE-DM).

METHODS

A total of 2799 asymptomatic patients with T2DM and no prior coronary disease were consecutively enrolled. OCAD was defined as ≥50% coronary artery stenosis on coronary computed tomography angiography (CCTA). A new risk scoring system was developed in 933 patients undergoing CCTA (derivation cohort) and its performance to predict OCAD and major adverse cardiac and cerebrovascular event (MACCE) was compared with other risk estimates. The scoring system was externally validated in 1899 patients not undergoing CCTA (validation cohort).

RESULTS

The PRECISE-DM scoring system was created using seven variables that were associated with increased risk of OCAD, with scores ranging from 0 to 9. The scoring system predicted presence of OCAD with a C-statistic of 0.680 and risk of MACCE with a C-statistic of 0.708. The UKPDS risk engine and the Framingham risk score showed unreliable performance in prediction of OCAD (C-statistics 0.531 and 0.577, respectively). Calcium score was highly predictive for OCAD (C-statistic 0.825) but showed only modest accuracy in predicting MACCE (C-statistic 0.675). In the external validation cohort, the PRECISE-DM score showed acceptable discrimination for prediction of MACCE (C-statistic 0.707).

CONCLUSIONS

The PRECISE-DM scoring system accurately predicted presence of OCAD and risk of MACCE in asymptomatic patients with T2DM.

Perception of diabetes management and cardiovascular disease risk among men with type 2 diabetes: A qualitative study

Aim

The aim of this study was to explore the perception and understanding of men with type 2 diabetes about their illness control, risk for CVD and their adherence to healthcare management plans in Jordan.

Design

A qualitative descriptive design was used, recruiting a purposive sample of 13 men diagnosed with type 2 diabetes.

Methods

Data were collected between February and April 2019 through in-depth semi-structured interviews and analysed using content analysis.

Results

Data analysis revealed four themes: (a) Perception of diabetes control; (b) Perception of cardiovascular disease risk; (c) Coping with disease-imposed limitations; and (d) Information validation.

Conclusion

The study concludes that the perception of disease control does not necessarily coincide with actual disease control. Examining patients with diabetes perception and knowledge of their healthcare management and increased CVD risks is essential. An individualized culture and gender-sensitive health education and counselling involving spouses are recommended. Social media to disseminate scientific valid health instructions can enhance adherence.

Perioperative management of adult diabetic patients. Preoperative period

In diabetic patients undergoing surgery, we recommend assessing glycaemic control preoperatively by assessing glycated haemoglobin (HbA1c) levels and recent capillary blood sugar (glucose) levels, and to adjust any treatments accordingly before surgery, paying particular attention to specific complications of diabetes. Gastroparesis creates a risk of stasis and aspiration of gastric content at induction of anaesthesia requiring the use of a rapid sequence induction technique. Cardiac involvement can be divided into several types. Coronary disease is characterised by silent myocardial ischaemia, present in 30-50% of T2D patients. Diabetic cardiomyopathy is a real cause of heart failure. Finally, cardiac autonomic neuropathy (CAN), although rarely symptomatic, should be investigated because it causes an increased risk of cardiovascular events and a risk of sudden death. Several signs are suggestive of CAN, and confirmation calls for close perioperative surveillance. Chronic diabetic kidney disease (diabetic nephropathy) aggravates the risk of perioperative acute renal failure, and we recommend measurement of the glomerular filtration rate preoperatively. The final step of the consultation concerns the management of antidiabetic therapy. Preoperative glucose infusion is not necessary if the patient is not receiving insulin. Non-insulin drugs are not administered on the morning of the intervention except for metformin, which is not administered from the evening before. The insulins are injected at the usual dose the evening before. The insulin pump is maintained until the patient arrives in the surgical unit. It should be remembered that insulin deficiency in a T1D patient leads to ketoacidosis within a few hours.

Silent coronary heart disease in patients with type 2 diabetes: application of a screening approach in a follow-up study

AIMS

The cost-effectiveness of screening for silent coronary heart disease (CHD) in type 2 diabetes (DM2) is still debated.

METHODS

We applied a diagnostic algorithm for silent CHD detection, in a cohort of 102 asymptomatic DM2 subjects (57±7years), attending 5 Italian outpatient clinics, to verify its predictive value. The risk of silent CHD was calculated considering classical risk factors, and presence of microangiopathy/macroangiopathy. Patients were divided in 3 groups, i.e. group 1: normal ECG and low silent CHD risk; group 2: abnormal ECG, irrespective of silent CHD risk; group 3: high silent CHD risk, irrespective of ECG. To group 2 and 3, a functional test was recommended and performed in 78% of patients.

RESULTS

Silent CHD prevalence was similar in group 2 and 3 (25 vs. 17% respectively; p=0.495). However, evaluating the entire cohort, a significant higher prevalence of silent CHD was observed in subjects with abnormal vs. normal ECG (23 vs. 4%; P=0.004), but not in subjects with high vs. low pre-test silent CHD risk (14 vs. 9%; p=0.472).

CONCLUSIONS

An abnormal ECG was a strong, independent predictor of silent CHD (OR 8.9; CI 1.27-62.5; p=0.028) in DM2. Therefore, a functional stress testing should be considered in DM2 patients with ECG abnormalities.

Atherogenic dyslipidemia and risk of silent coronary artery disease in asymptomatic patients with type 2 diabetes: a cross-sectional study

Background

To investigate whether atherogenic dyslipidemia, a dyslipidemic profile combining elevated triglycerides and low high-density lipoprotein (HDL) cholesterol, is predictive of risk of silent myocardial ischemia (SMI) or angiographic coronary artery disease (CAD) in asymptomatic patients with type 2 diabetes.

Methods

Cohort study in 1080 asymptomatic patients with type 2 diabetes with a normal resting electrocardiogram, at least one additional cardiovascular risk factor and low density lipoprotein (LDL) cholesterol <3.35 mmol/L. Patients initially underwent screening for SMI by stress myocardial scintigraphy. Patients with SMI underwent coronary angiography.

Results

Overall, 60 (5.5 %) patients had atherogenic dyslipidemia (triglycerides ≥2.26 mmol/L and HDL cholesterol ≤0.88 mmol/L). In multivariate analyses taking into account the parameters associated in univariate analyses with SMI and then CAD, atherogenic dyslipidemia was associated with SMI (odds ratio 1.8[1.0–3.3]), as were male gender (OR 2.1[1.5–2.9]), BMI (OR 0.97[0.94–0.997]), retinopathy (OR 1.4[1.1–1.9]), peripheral occlusive arterial disease (POAD: OR 2.5[1.6–3.8]) and mean blood pressure (OR 1.01[1.00–1.03]); atherogenic dyslipidemia was associated with CAD (OR 4.0[1.7–9.2]), as were male gender (OR 3.0[1.6–5.6]), BMI (OR 0.94[0.90–0.995]), retinopathy (OR 1.7[1.0–2.9], POAD (OR 4.0[2.1–7.4]) and mean blood pressure (OR 1.03[1.01–1.05]). In the subgroup of 584 patients with LDL cholesterol <2.6 mmol/L, atherogenic dyslipidemia was also associated with CAD (OR 3.6[1.5–9.0]).

Conclusions

Atherogenic dyslipidemia was associated with an increased risk of SMI and silent CAD in patients with type 2 diabetes and LDL cholesterol levels <3.35 mmol/L. Specific management of atherogenic dyslipidemia might help reducing the high residual burden of cardiovascular disease.

Screening for asymptomatic coronary artery disease in patients with diabetes mellitus: A systematic review and meta-analysis of randomized trials

Background

Screening diabetic patients for the presence of asymptomatic coronary artery disease (CAD) may potentially impact therapeutic management and outcome. We performed a systematic review and meta-analysis of randomized trials addressing this question.

Methods

We searched the PubMed database for studies reporting a randomized comparison of systematic screening for CAD in diabetic patients versus no systematic screening. The screening protocols were variable with the use of exercise electrocardiogram test, or stress echocardiography, or nuclear test, or coronary computed tomography angiography.

Results

The final analysis included 5 randomized studies and 3,314 patients altogether. The screening strategy had no detectable impact on outcome with odds ratios (OR) [95 % confidence interval (CI)] of 1.00 [0.67–1.50], 0.72 [0.33–1.57], 0.71 [0.40–1.27], and 0.60 [0.23–1.52] for all-cause death, cardiovascular death, non-fatal myocardial infarction, and the composite cardiovascular death or non-fatal myocardial infarction, respectively. Protocol-related coronary procedures were relatively infrequent in screened patients: coronary angiography was performed in 8 % of the cases, percutaneous coronary intervention in 2.5 %, and coronary artery bypass surgery in 1.5 %. There was no evidence for an effect of screening on the use of statins (OR = 1.19 [0.94–1.51]), aspirin (OR = 1.02 [0.83–1.25]), or angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (OR = 0.97 [0.79–1.19]).

Conclusion

The present analysis shows no evidence for a benefit of screening diabetic patients for the presence of asymptomatic CAD. The proportion of patients who undergo myocardial revascularization as a consequence of screening was low.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0256-9) contains supplementary material, which is available to authorized users.

A post hoc analysis of saxagliptin efficacy and safety in patients with type 2 diabetes stratified by UKPDS 10-year cardiovascular risk score

BACKGROUND AND AIMS

To assess the efficacy and safety of saxagliptin 2.5 and 5 mg/d in patients with type 2 diabetes mellitus (T2DM) and high risk of coronary heart disease (CHD) or stroke as estimated by the United Kingdom Prospective Diabetes Study (UKPDS) risk engine.

METHODS AND RESULTS

Post hoc analysis of data pooled from 5 previously reported phase 3, randomized, placebo-controlled, 24-week studies was conducted. Patients were stratified into subgroups by UKPDS 10-year CHD and/or stroke risk ≥20% and CHD and stroke risk <20%. End points were adjusted mean change from baseline in glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), 120-min postprandial glucose (PPG), and body weight and the proportion of patients achieving HbA1c <7% and ≤8% at week 24. Pooled safety data were analyzed for adverse events (AEs) and hypoglycemia. Both doses of saxagliptin reduced HbA1c, FPG, and PPG to a greater extent than placebo regardless of UKPDS risk score. The proportions of patients achieving HbA1c <7% and ≤8% were greater with saxagliptin than placebo and consistent across risk score groups. AE profile and hypoglycemia incidence were similar for saxagliptin and placebo across UKPDS risk score groups.

CONCLUSION

Saxagliptin was well tolerated and improved glycemic control in patients with T2DM regardless of their CHD and stroke UKPDS risk score. Clinical trial registration numbers: Clinicaltrials.gov NCT00121641, NCT00316082, NCT00121667, NCT00313313, and NCT00295633.

Gender differences in the progression of target organ damage in patients with increased insulin resistance: the LOD-DIABETES study

BACKGROUND

The purpose of this study was to analyze the evolution of vascular, cardiac and renal target organ damage (TOD) in patients with increased insulin resistance over a 3.5 year follow-up and to investigate gender difference and factors that influence its progression.

METHODS

We performed a prospective observational study involving 112 patients (71 men, 41 women) who were followed for 3.5 years. Measurements included blood pressure, blood glucose, lipids, smoking, body mass index (BMI) and HOMA-Ir Vascular TOD included carotid intima-media thickness (IMT), pulse wave velocity (PWV) and ankle/brachial index (ABI). Cardiac TOD included Cornell voltage-duration product and Sokolow. Renal TOD included creatinine, glomerular filtration and albumin/creatinine ratio.

RESULTS

The IMT increased in both genders. Each year, the IMT increased 0.005 mm in men and 0.011 in women and the PWV 0.024 and 0.020 m/sec, respectively. The highest increase was in women with type 2 diabetes mellitus, who had an increase in TOD carotid (40%), PWV (24%) and renal TOD (20 %). Multiple regression analysis, after adjusting for age and gender, showed a negative association between duration since diabetes diagnosis and ABI (β = -0.006; p = 0.017) and between BMI and glomerular filtration (β = -0.813; p = 0.014). HbA1c was positively associated with PWV (β = 0.501; p = 0.014).

CONCLUSIONS

This study showed that the progression of vascular and renal TOD differs by gender. The increase in vascular and renal TOD was higher in women, especially in diabetic women. The PWV increase showed a positive association with mean HbA1c levels during the follow-up. Glomerular filtration was associated with BMI and the ABI was associated with duration since type 2 diabetes mellitus diagnosis.

TRIAL REGISTRATION

Clinical Trials.gov Identifier NCT01065155.

Risk stratification of coronary artery disease in asymptomatic diabetic subjects using multidetector computed tomography

BACKGROUND

Patients with type 2 diabetes mellitus (T2DM) show a greater risk for coronary artery disease (CAD), but the risk stratification in asymptomatic CAD patients has not been established. This study investigated the prevalence and severity for asymptomatic CAD and predictors in T2DM patients.

METHODS AND RESULTS

In a multiclinic group, diabetic patients (320 men, 186 women) without known symptoms suggestive of CAD were recruited for multidetector computed tomography (MDCT). Patients were categorized according to severity of coronary atherosclerosis: Grade 1 (normal findings), Grade 2 (mild atherosclerosis without significant stenosis), Grade 3 (moderate stenosis/atherosclerosis, 50-74% stenosis), Grade 4 (moderate stenosis/atherosclerosis, 75-89% stenosis), Grade 5 (severe stenosis/atherosclerosis, ≥90% stenosis). The trend for severity grade of CAD was slightly higher in men than women (P=0.054). For critical lesions (combined Grades 3-5), the prevalence was almost equal (men 44% vs. women 37%; P=0.113). Multivariate models showed that in men, HbA1c≥7.4%, dyslipidemia, duration of diabetes, retinopathy, and other type of cardiovascular diseases were predictors of critical lesions and in women, duration of diabetes and retinopathy were predictors.

CONCLUSIONS

The prevalence and severity of asymptomatic CAD are comparably high in men and women with T2DM. Risk stratification by using MDCT might be useful to predict asymptomatic coronary lesions requiring coronary revascularization.

Noninvasive study of coronary microcirculation response to a cold pressor test

BACKGROUND

The aims of this study were to noninvasively (i) assess the coronary microcirculation changes in response to a cold pressor test (CPT) in control subjects, nondiabetic obese patients and patients with type 2 diabetes and (ii) investigate the response of the coronary microcirculation in patients with diabetes according to the presence or the absence of silent myocardial ischaemia (SMI), asymptomatic coronary stenosis (CS) and left ventricle hypertrophy (LVH).

METHODS

The mean left anterior descending coronary flow velocity (mCFV) was measured using transthoracic Doppler before and after a CPT in 16 control subjects, 11 obese and 66 asymptomatic diabetic patients with a high cardiovascular risk. Patients with diabetes were screened for SMI using stress myocardial scintigraphy and/or echocardiography. A coronary angiography was performed in those with SMI.

RESULTS

At baseline, pressure-rate product (PRP) was correlated with mCFV (r = 0.23; P < 0.05) and left ventricle mass (r = 0.26; P < 0.05) in the whole population. Changes in PRP and mCFV during CPT were correlated with controls (r = 0.58, P < 0.05), obese (r = 0.75, P < 0.01) and diabetic patients without CS (r = 0.56, P < 0.0001) or without LVH (r = 0.63, P < 0.05) but not in diabetic patients with CS or with LVH. In patients with diabetes, SMI was associated with mCFV changes, independent of other parameters (P < 0.05).

CONCLUSION

Transthoracic coronary Doppler allows noninvasive study of changes in the coronary microcirculation during CPT. In asymptomatic patients with type 2 diabetes, this method showed that SMI was associated with mCFV changes during CPT and the presence of CS or LVH was associated with a mismatch between coronary microcirculation and myocardial oxygen demand.

Subclinical cardiovascular disease in type 2 diabetes mellitus: To screen or not to screen

The prevalence of type 2 diabetes mellitus (T2DM) has risen in recent decades, and cardiovascular disease remains the leading cause of death in this population. Several clinical trials have demonstrated the benefit of tight control of risk factors on the incidence and mortality of cardiovascular disease. However, in clinical practice, few patients achieve the therapeutic goals. The current diagnostic procedures for subclinical cardiovascular disease in T2DM patients have not been shown to improve prognosis or mortality, probably because they do not categorize cardiovascular risk. Thus, clinical practice guidelines do not systematically recommend screening for subclinical atherosclerosis in these patients, although it is known that patients with extra-coronary atherosclerosis, microangiopathy and poorly-controlled cardiovascular risk factors are at high risk for cardiovascular disease. Improvements in the reliability of diagnostic tests, with fewer side effects and better cost efficiency, may better help to stratify cardiovascular risk in this group of patients, and further evaluation on this topic should be considered.

Cardiovascular disease in diabetes mellitus: risk factors and medical therapy

Cardiovascular disease is a serious complication of diabetes mellitus. In the last 2 decades, great strides have been made in reducing microvascular complications in patients with diabetes through improving glycemic control. Decreasing rates of cardiovascular events have proved to be more difficult than simply intensifying the management of hyperglycemia. A tremendous effort has been made to deepen understanding of cardiovascular disease in diabetes and to formulate the best treatment approach. This review summarizes the current state of knowledge and discusses areas of uncertainty in the care of patients with diabetes who are at risk for cardiovascular disease.

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.

Diagnostic accuracy of heart-rate recovery after exercise in the assessment of diabetic cardiac autonomic neuropathy

AIMS

Poor prognosis associated with blunted post-exercise heart-rate recovery may reflect autonomic dysfunction. This study sought the accuracy of post-exercise heart-rate recovery in the diagnosis of cardiac autonomic neuropathy, which represents a serious, but often unrecognized complication of Type 2 diabetes.

METHODS

Clinical assessment of cardiac autonomic neuropathy and maximal treadmill exercise testing for heart-rate recovery were performed in 135 patients with Type 2 diabetes and negative exercise echocardiograms. Cardiac autonomic neuropathy was defined by abnormalities in ≥ 2 of 7 autonomic function markers, including four cardiac reflex tests and three indices of short-term (5-min) heart-rate variability. Heart-rate recovery was defined at 1-, 2- and 3-min post-exercise.

RESULTS

Patients with cardiac autonomic neuropathy (n = 27; 20%) had lower heart-rate recovery at 1-, 2- and 3-min post-exercise (P < 0.01). Heart-rate recovery demonstrated univariate associations with autonomic function markers (r-values 0.20-0.46, P < 0.05). Area under the receiver-operating characteristic curve revealed good diagnostic performance of all heart-rate recovery parameters (range 0.80-0.83, P < 0.001). Optimal cut-offs for heart-rate recovery at 1-, 2- and 3-min post-exercise were ≤ 28 beats/min (sensitivity 93%, specificity 69%), ≤ 50 beats/min (sensitivity 96%, specificity 63%) and ≤ 52 beats/min (sensitivity 70%, specificity 84%), respectively. These criteria predicted cardiac autonomic neuropathy independently of relevant clinical and exercise test information (adjusted odds ratios 7-28, P < 0.05).

CONCLUSIONS

Post-exercise heart-rate recovery provides an accurate diagnostic test for cardiac autonomic neuropathy in Type 2 diabetes. The high sensitivity and modest specificity suggests heart-rate recovery may be useful to screen for patients requiring clinical autonomic evaluation.

Clinical review: Screening for coronary artery disease in type 2 diabetes

CLINICAL CONTEXT

Sensitive tools are available to diagnose occult ischemic and atherosclerotic coronary disease, yet screening for coronary artery disease (CAD) has not been shown to reduce cardiac events in patients with type 2 diabetes mellitus (T2DM). Professional guidelines are inconsistent regarding CAD screening recommendations, but it is suggested that those at highest risk (10-yr risk ≥20%) for cardiac events may benefit.

EVIDENCE ACQUISITION

We reviewed bibliographies of professional CAD screening guidelines, review articles, and clinical trials published within the last 10 yr, although we have included relevant older studies. We excluded studies that did not focus on T2DM or explicitly analyze that subgroup.

EVIDENCE SYNTHESIS

Although screening for coronary ischemia or atherosclerosis does provide incremental prognostic information in patients with T2DM and previously undiagnosed CAD, this has not been found to significantly impact outcomes. This appears to result from comparable efficacy of revascularization and optimal medical therapy in stable CAD. Limited evidence supports the hypothesis that those with more severe CAD (three-vessel, left main, proximal left anterior descending) amenable to bypass surgery may be potential beneficiaries of screening. However, the low prevalence of such candidates in the asymptomatic population, continuing advances with percutaneous intervention, and the lack of prospective trials makes such a recommendation currently unsupportable.

CONCLUSIONS

Findings to date do not support widespread screening for CAD in patients with T2DM. A future strategy identifying those at highest risk as screening candidates may ultimately be effective, but the optimal method for selecting those subjects or subsequent treatment is unknown.

Coronary artery disease is detectable by multi-slice computed tomography in most asymptomatic type 2 diabetic patients at high cardiovascular risk

OBJECTIVE

Non-invasive testing often does not identify coronary artery disease (CAD) in diabetic subjects. This study was designed in order to examine the prevalence of CAD in a cohort of asymptomatic type 2 diabetic patients at high cardiovascular risk and negative nuclear imaging, using multi-slice computed tomography (MSCT) angiography.

METHODS

In total, 770 type 2 diabetic patients were screened from January 2008 through July 2010. Of these, 132 Caucasians with diabetic nephropathy and asymptomatic for angina were eligible for a cross-sectional study. Patients underwent MSCT after ischaemia was excluded by myocardial Single Photon Emission Computed Tomography (SPECT) at rest and after dynamic exercise. When obstructive plaques were found (≥ 50% lumen narrowing), patients were sent to conventional coronary angiography (CCA).

RESULTS

Six subjects were not included in the analysis because of motion artefacts. MSCT was positive for CAD in 114 patients (90%). Within patients with positive MSCT, 60 (48% of all) showed one or more obstructive plaques. CCA confirmed significant stenosis (≥ 50%) in 48 of these 60 patients (80%). Some 21 (35%) showed stenosis ≥ 75% and were submitted to the revascularisation procedure.

CONCLUSION

MSCT seems to better identify CAD than myocardial SPECT in asymptomatic patients with type 2 diabetes and diabetic nephropathy.