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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, Michael Oettinger, MD, Rosa Levy, Abraham Caspi, MD, David Faraggi, PhD and Shay Livschitz, MD

^* Metabolic Unit, Kaplan Medical Center, affiliated with Hadassah and the Hebrew University School of Medicine, Rehovot, Israel
Department of Statistics, Haifa University, Haifa, Israel
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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