CORRESPONDENCE: LETTER TO THE EDITOR
Most Asymptomatic Diabetic Patients Will Not Benefit From Coronary Revascularization
David Rott, MD, FACC, FESC* and
David Leibowitz, MD, FACC
* Department of Medicine, Hadassah–Hebrew University Medical Center, Mt. Scopus, Jerusalem 97654, Israel (Email: drott{at}012.net.il).
In a study recently published in JACC
, Scognamiglio et al. (1
) suggest that patients with type 2 diabetes mellitus with  1 other risk factor should undergo routine stress imaging to diagnose asymptomatic coronary artery disease (CAD), a strategy the investigators believe will lead to early aggressive medical treatment and more favorable coronary anatomy that is more suitable for revascularization.
As cited by Scognamiglio et al. (1
), the risk of major coronary events in diabetic patients is similar to that of nondiabetic patients with established coronary disease. Risk factors in these patients should be treated as aggressively as in CAD patients even without evidence of CAD on diagnostic imaging. Therefore, routine assessment of asymptomatic diabetic patients by stress imaging to clarify the need for more aggressive risk-factor modification is not warranted.
Both coronary revascularization by surgery (coronary artery bypass graft [CABG]) and percutaneous coronary intervention (PCI) differ in their influence on prognosis. Although no randomized study to date has shown PCI to improve elective patient prognosis, CABG improves survival of elective patients in 4 categories: patients with left main coronary disease; patients with 3-vessel disease and decreased left ventricular function; patients with multivessel disease involving the proximal left anterior descending artery; and patients with diabetes mellitus and multivessel disease (2
). Most other patients undergo revascularization for control of symptoms. For asymptomatic patients to benefit prognostically from revascularization, one of the 4 previously mentioned indications must apply (and the procedure should be CABG), otherwise no mortality benefit should be anticipated. Revascularization, therefore, should be limited to patients who are symptomatic or fall under 1 of the 4 previously mentioned categories. Noninvasive testing should be performed in asymptomatic diabetics only if clinical assessment suggests that they belong to a high-risk group. Only those patients with impaired cardiac function or high-risk stress imaging should undergo coronary angiography.
Early detection and aggressive modification of non–insulin-dependent diabetes mellitus and other risk factors in adherence to published guidelines (3,4
) will help prevent CAD and its complications, whereas routine stress imaging and revascularization for the most part will not.
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References
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1. Scognamiglio R, Negut C, Ramondo A, Tiengo A, Avogaro A. Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus J Am Coll Cardiol 2006;47:65-71.[Abstract/Free Full Text]2. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: summary article J Am Coll Cardiol 2004;44:e213-e310.[Free Full Text] 3. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article J Am Coll Cardiol 2003;41:159-168.[Free Full Text] 4. Mosca L, Appel LJ, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women J Am Coll Cardiol 2004;43:900-921.[Abstract/Free Full Text]
Related Article
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Reply
- Roldano Scognamiglio
J. Am. Coll. Cardiol. 2006 48: 1917.
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