CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Roldano Scognamiglio, MD*
* Cardiologia Metabolica, Policlinico Universitario, University of Padua, via Giustiniani 2, 35128 Padova, Italy (Email: r.scognamiglio{at}unipd.it).
In their letter, Drs. Rott and Leibowitz correctly reported the current indications to myocardial revascularization in type 2 diabetic (DM2) patients, and they concluded that an aggressive diagnostic approach (like that used in our study) (1
) may not be useful. Unfortunately, they do not take into account that previous results with percutaneous coronary intervention or aorto-coronary artery bypass have been obtained applying an old, bankrupt diagnostic approach to ischemic heart disease (IHD) in DM2 patients. In fact, in the past 20 years, cardiovascular mortality (mainly due to IHD) increased by 40% to 50% in diabetic patients, whereas in the same period of observation, major cardiovascular disease mortality in the nondiabetic population was reduced by about 30% (2
). The poor results of myocardial revascularization procedures in DM2 patients are largely caused by the extension of atherosclerotic involvement of coronary artery disease (CAD) at the moment of diagnosis. The current American Diabetes Association guidelines (3,4
) do not allow for the identification of a population of diabetic patients with a high prevalence of CAD but only those DM2 patients with advanced atherosclerosis involving multiple coronary vessels. Similar results may be obtained by applying the suggestion reported by Drs. Rott and Leibowitz in their letter: "Noninvasive testing should be performed in asymptomatic diabetics only if clinical assessment suggests that they belong to a high-risk group." But all diabetic patients belong to a high-risk group for cardiovascular mortality!
In an autopsy study, Goraya et al. (5
) showed that, among diabetic decedents without clinical CAD, almost three-fourths had high-grade atherosclerosis and more than one-half had multivessel coronary disease. Moreover, Haffner et al. (6
) showed that diabetic patients who have not had a previous myocardial infarction (MI) have outcomes similar to those of patients without diabetes who have had a prior MI. In light of these statements we applied to DM2 patients a diagnostic approach similar to one that is currently applied in nondiabetic patients with clinical manifestation of CAD. The diagnostic approach we proposed in our study (1
) allowed us to identify an early phase of CAD in asymptomatic diabetic patients, and the favorable anatomy of coronary vessels (with the high prevalence of one-vessel disease) has the potential to improve results of revascularization procedures and the rate of cardiac events in asymptomatic diabetic patients.
Finally, in our opinion, we must not be resigned to accept the current bankrupt diagnostic and therapeutic approach to ischemic heart disease in diabetic patients, and research into a "New Deal" is mandatory.
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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. Sobel BE, Frye R, Detre KM. Burgeoning dilemmas in the management of diabetes and cardiovascular disease: rationale for the Bypass Angioplasty Revascularization Investigations 2 Diabetes (BARI 2D) trial Circulation 2003;107:636-642.[Abstract/Free Full Text] 3. Barrett EJ, Ginsberg HN, Pauker SG, et al. Consensus development conference on the diagnosis of coronary artery disease in people with diabetes Diabetes Care 1998;21:1551-1559.[Medline] 4. American Diabetes Association Standards of medical care in diabetes (position statement) Diabetes Care 2005;28(Suppl 1):S4-S36.[Free Full Text] 5. Goraya TY, Leibson CL, Palumbo JP, et al. Coronary atherosclerosis in diabetes mellitusA population-based autopsy studyA population-based autopsy study. J Am Coll Cardiol 2002;40:946-953.[Abstract/Free Full Text] 6. Haffner SM, Lehto S, Ronnemaa T, et al. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction N Engl J Med 1998;339:22-34.
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