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J Am Coll Cardiol, 2004; 44:2142-2148, doi:10.1016/j.jacc.2004.09.006
© 2004 by the American College of Cardiology Foundation
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CORONARY ARTERY DISEASE

Reduced glomerular filtration rate in asymptomatic diabetic patients

Predictor of increased risk for cardiac events independent of albuminuria

Hilla Knobler, MD*,*, Taiba Zornitzki, MD*, Shiraz Vered{dagger}, Michael Oettinger, MD{ddagger}, Rosa Levy{ddagger}, Abraham Caspi, MD{ddagger}, David Faraggi, PhD{dagger} and Shay Livschitz, MD{ddagger}

* Metabolic Unit, Kaplan Medical Center, affiliated with Hadassah and the Hebrew University School of Medicine, Rehovot, Israel
{dagger} Department of Statistics, Haifa University, Haifa, Israel
{ddagger} Institute of Cardiology, Kaplan Medical Center, Rehovot, Israel

Manuscript received July 3, 2004; revised manuscript received August 18, 2004, accepted September 2, 2004.

* Reprint requests and correspondence: Dr. Hilla Knobler, Head of Metabolic Unit, Kaplan Medical Center, Rehovot, Israel 76100 (Email: knobler{at}inter.net.il).

OBJECTIVES: This study aimed to investigate the prevalence of a reduced glomerular filtration rate (GFR) with and without albuminuria and its ability to predict cardiac events in asymptomatic diabetic patients undergoing stress-rest thallium-201 myocardial perfusion single-photon emission computed tomography.

BACKGROUND: Diabetic patients have a higher prevalence of asymptomatic coronary heart disease. Therefore, identifying predictors of cardiac events in asymptomatic diabetic patients is needed.

METHODS: In 269 asymptomatic patients, baseline evaluation included diabetes-related complications, including creatinine clearance (CrCl) and albuminuria. During follow-up (mean 2.3 ± 1.0 years), all cardiac events were recorded.

RESULTS: Seventy-seven patients (29%) had a reduced GFR defined by CrCl <60 ml/min/1.73 m2. Compared with the 177 patients with CrCl ≥60 ml/min/1.73 m2, the reduced GFR group was older (p < 0.0001), had a longer duration of diabetes (p = 0.002), and had a higher prevalence of albuminuria (p = 0.04). Nevertheless, 35% of the reduced GFR group had normoalbuminuria. Patients with reduced GFR had a significant two-fold increase in total cardiac events (unstable angina, nonfatal myocardial infarction, and cardiac procedures) (25% vs. 13%, p = 0.019), and multivariate analysis found that reduced GFR was an independent predictor of cardiac events (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.1 to 4.46). Other independent predictors of cardiac events included stress-induced abnormal myocardial perfusion imaging (OR 3.1, 95% CI 1.3 to 7.5), an electrocardiographic ischemic response (OR 2.7, 95% CI 1.01 to 7.14), and peripheral artery disease (OR 2.1, 95% CI 1.05 to 4.23); however, albuminuria was not.

CONCLUSIONS: A reduced GFR was common in our group of asymptomatic diabetic patients and was associated with a two-fold increase in cardiac events. Multivariate analysis found that reduced GFR independent of albuminuria was a significant predictor of cardiac events.

Abbreviations and Acronyms
  CAD = coronary artery disease
  CI = confidence interval
  CrCl = creatinine clearance
  CVD = cardiovascular disease
  DM = diabetes mellitus
  ECG = electrocardiogram/electrocardiographic
  GFR = glomerular filtration rate
  OR = odds ratio
  PVD = peripheral vascular disease
  SPECT = single-photon emission computed tomography




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