Coronary Atherosclerosis

Several clinical observations, most notably those reported from the Framingham study, have shown that the incidence and prevalence of the major clinical manifestations of atherosclerotic coronary artery disease (CAD) are increased in patients with diabetes (4). This is independent of the other risk factors such as arterial hypertension, male gender, and dyslipidemia. CAD is the major cause of morbidity and mortality in patients with diabetes, with a mortality rate that is three times as high as in those without diabetes. The clinical indications for performing noninvasive and invasive tests for the purpose of detection or risk stratification of CAD in patients with diabetes largely parallel those of the nondiabetic population. However, certain aspects with regard to evaluation of CAD in patients with diabetes merit special consideration.

Although a standard exercise treadmill test is economical and widely available, in diabetic patients who are at an increased risk for CAD a treadmill test is less sensitive; hence a stress imaging test would be more valuable. The sensitivity and specificity for the detection of coronary artery disease among patients with diabetes was 75% and 77% for the exercise test and 80% and 87% for thallium myocardial scintigraphy (5). This supports the use of noninvasive imaging tests for the detection of coronary artery disease, especially in those patients who have multiple cardiac risk factors. The sensitivity and specificity of stress echocardiography is comparable to that of nuclear SPECT imaging study in the general population, and it is reasonable to assume that the same should also be true for diabetic patients, although comparative studies are not available. The decision to refer a patient for a nuclear or echocardiographic stress test should be based on the available resources and local expertise. Among diabetics with significant peripheral vascular disease, a pharmacological stress test may lend higher sensitivity and specificity for the detection of significant CAD. It should be noted that, in some studies, exercise electrocardiography as well as radionuclide imaging are somewhat less accurate in patients with hypertension, established diabetic or autonomic cardiomyopathy, renal insufficiency, or microvascular disease (3).

The clinical impression that patients with diabetes tend to have a higher incidence of silent myocardial infarctions was challenged with data emerging from the 30-year follow-up analysis of the Framingham study (6). Nevertheless, -o it has been clearly established that the prevalence of significant CAD in asymptomatic diabetic patients is substantially higher compared to nondiabetic control subjects. In diabetic patients with additional risk factors for coronary atherosclerosis, periodic thorough clinical examination and resting ECG may fail to detect <j significant CAD (7). Thus, it is reasonable to consider noninvasive imaging stress Ji tests as part of the periodic care, especially in those with two or more cardiovascu- J

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