DOCTOR'S VIEW ARCHIVE
Diabetes Update #12 Day 4, Monday June 13 from the American Diabetes Association National Meeting
Dr. Ruchi Mathur offers perspectives of interest on topics from the American Diabetes Association's 65th Annual Scientific Sessions (held in San Diego, California June 10-14, 2005)
This is Dr. Ruchi Mathur bringing up another update from the 65th annual scientific sessions of the American Diabetes Association. I would like to tell you about a study looking at heart disease in people with type 2 diabetes who have no symptoms.
Coronary artery disease often presents differently in diabetes. The accompanying neuropathy contributes to the " silent" (or painless) heart attacks we see in patients with diabetes. This makes it difficult to assess patients with diabetes for heart disease, and physicians often are concerned that they may be either missing patients who should be screen, or wasting resources evaluating patients without pain simply because they have diabetes.
In a 3-hour symposia, the following question was raised for discussion: What is the prevalence of silent ischemia (or poor blood flow to the heart) in patients with diabetes who have never had any chest pain?
The speakers presented the DIAD study results to help answer this question. This study is expected to finish in 2007, and what were presented were the results up to this point. Basically this study took 1124 patients with type 2 diabetes who were between 50-75 years old, with no history of angina, coronary artery disease, and normal EKG and no chest pain and divided them into 2 groups. One group was simply followed, with no intervention. The other group of about 561 patients underwent a sestamibi test to look for any evidence of heart disease.522 in this group went on, and of these 113 were found to have abnormal test results. When reviewed in detail to see if there was anything that could have predicted who would be in this positive group (cholesterol, A1c, age, blood pressure, smoking, etc) the only thing that predicted an abnormality in testing was the presence of autonomic neuropathy, and to a smaller degree, being male and being overweight were also associated risk factors.
Interestingly, the current recommendations for investigation of heart disease in diabetes relies on 2 or more risk factors. However in this group found to have a positive test, 41% had 2 or less risk factors, and probably would not have been screened and tested based on current standards of care.
What does this mean? In this study population of asymptomatic patients with type 2 diabetes, 22% had abnormalities on Sestamibi testing, and 6% of these were severe There is really nothing to predict this, except a finding of cardiac autonomic dysfunction. A significant proportion of this population has less than 2 risk factors, yet still have significant disease.
We may need to reconsider guidelines for the screening of heart disease in diabetes, since studies like this raise the issue of missing significant disease in patients who may not have risk factors or who may be asymptomatic.
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