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COUNTERPOINT

Screening Asymptomatic Diabetic Patients for Coronary Artery Disease

Why Not?

Todd D. Miller, MD, FACC^_*,_*, Rita F. Redberg, MD, MSc, FACC and Frans J.T. Wackers, MD, FACC

^_* Mayo Clinic, Rochester, Minnesota
University of California, San Francisco, California
Yale University, New Haven, Connecticut.

Manuscript received January 27, 2006; revised manuscript received March 20, 2006, accepted April 4, 2006.

^_* Reprint requests and correspondence: Dr. Todd D. Miller, Mayo Clinic, Gonda 5-412, 200 First Street, SW, Rochester, Minnesota 55901. (Email: miller.todd{at}mayo.edu).

Given the elevated risk of cardiovascular events and the higher prevalence of silent coronary artery disease (CAD) in diabetic versus non-diabetic patients, screening asymptomatic diabetic patients for CAD is an appealing concept. However, many factors argue against implementing a broad-based screening program at the present time. Foremost is the lack of any published data demonstrating that a prospectively applied screening program improves outcome in asymptomatic diabetic patients. The true prevalence of CAD, and in particular prognostically important CAD, in this population is uncertain. Consensus documents recommend more aggressive treatment of hypertension and hyperlipidemia solely on the basis of diabetes status, without differentiation based on the presence or absence of identifiable CAD. There is no evidence that use of anti-ischemic medication can alter the natural history of CAD in these patients. Retrospectively performed studies using stress single-photon emission computed tomography (SPECT) imaging have reported that approximately 50% and 20% of patients have abnormal and high-risk images, respectively. However, the only prospectively designed study, the DIAD (Detection of Ischemia in Asymptomatic Diabetics) study, reported a much lower percentage of abnormal SPECT images (16%) and images with a very large (10% of the left ventricle) defect (1%). The financial implications of screening all asymptomatic diabetic patients determined to be at intermediate and high risk by clinical scoring systems is enormous. Clearly more data are needed to address this issue. Future studies should consider possible methods to enrich the patient subset that might benefit from screening and should include carefully performed cost-effective analyses.

Abbreviations and Acronyms   ACC = American College of Cardiology   AHA = American Heart Association   BARI = Bypass and Angioplasty Revascularization Intervention study   CABG = coronary artery bypass grafting   CAD = coronary artery disease   DIAD = Detection of Ischemia in Asymptomatic Diabetics study   NCEP = National Cholesterol Education Program   SPECT = single-photon emission computed tomography

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