Clinical Investigations: Imaging and Diagnostic Testing
Diabetes and the associated incidence of subclinical atherosclerosis and coronary artery disease: Implications for management

https://doi.org/10.1067/mhj.2001.113224Get rights and content

Abstract

Background We sought to examine the prevalence, sensitivity, and specificity of coronary calcium (CC), a marker of atherosclerosis, in a population of symptomatic and asymptomatic diabetic persons. Methods We used electron beam tomography (EBT) to quantitate CC in 168 symptomatic (chest pain or anginal equivalent) persons with diabetes who underwent coronary angiography and then compared this with a cohort of 155 asymptomatic persons with diabetes. Results In the 168 symptomatic diabetic persons, 124 (74%) had obstructive coronary artery disease (CAD) by angiography. Receiver-operator characteristic curve analysis was used to maximize sensitivity and specificity for obstructive CAD (>50% stenosis), which established a CC score of 102 as optimal. With use of this cut point, EBT has a sensitivity of 77% and a specificity of 77% for detecting obstructive CAD. Of the 155 asymptomatic diabetic persons, 72% had CC and 48% had a CC score >102. The presumed prevalence of obstructive disease (on the basis of EBT scores and prevalence of CC) among asymptomatic diabetic persons is quite high (as high as symptomatic persons without diabetes). Analyzing the 323 diabetic patients demonstrated no significant age difference in CC scores between women and men. Conclusions This study confirms that higher CC scores should be used in diabetic patients to improve the specificity of CC to determine obstructive disease. EBT can allow a noninvasive diagnosis of CAD before clinical presentation, allowing for more therapy for those in which CC is detected. These results suggest that asymptomatic diabetic persons have the same atherogenic burden of those patients with CAD without diabetes. The high prevalence of CC in asymptomatic persons with diabetes supports the need for aggressive management of diabetes and associated risk factors. (Am Heart J 2001;141:637-44.)

Section snippets

Patient population

We enrolled 2 cohorts of diabetic patients to evaluate the differences in prevalence and extent of disease. All patients underwent EBT for evaluation of CC.

Symptomatic cohort

The symptomatic population (n = 168) consisted of patients undergoing coronary angiography for suspicion of obstructive CAD. These symptomatic diabetic patients were excluded if patients declined to participate, refused to sign informed consent, or had previous revascularization. The patients enrolled consisted of almost exclusively type 2

Patient demographics

A total of 323 patients with diabetes, 208 men (64%) and 115 women (36%), were studied. The mean age was 58 ± 9 years, ranging from 31 to 82 years. Diabetic persons in our population were found to have an average of 2.06 nondiabetic cardiac risk factors, which included age, tobacco use, hypercholesterolemia, hypertension, and family history. There were no statistical differences between men and women with regard to prevalence of nondiabetic risk factors.

Symptomatic cohort

We enrolled 168 (52%) symptomatic

Diabetes as a cardiovascular risk factor

Cardiovascular disease is the cause of death in 65% of persons with diabetes, whereas only 35% of deaths in nondiabetic subjects can be attributed to CVD.7 The aggressive management of this cohort (especially in regard to widespread cholesterol therapy) is still somewhat controversial. It has been well established that CC is proportional to the atherosclerotic burden.13, 14, 15, 16, 17, 18 EBT allows for the detection and quantification of CC and is reproducible and independent of user

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    Reprint requests: Matthew J. Budoff, MD, FACC, St John’s Cardiovascular Research Center, 1124 W Carson St, RB2, Torrance, CA 90502. E-mail: [email protected]

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