ADD SOME
RELATED
PICTURE
WORLD BURDEN OF DIABETES
DID YOU KNOW?
 Diabetes currently affects 246 million people worldwide and is
expected to affect 380 million by 2025.
 I...
CARDIOVASCULAR DISEASE (CVD) IN
INDIVIDUALS WITH DIABETES
 CVD is the major cause of morbidity, mortality for those with
...
CARDIOVASCULAR DISEASE (CVD) IN
INDIVIDUALS WITH DIABETES
 Diabetes reflected by the four-fold greater incidence of CAD.
...
TYPE 1 DIABETES AND CORONARY ARTERY
DISEASE
 The excess coronary artery calcification (CAC) in type 1
diabetes seen in st...
TYPE 1 DIABETES AND CORONARY ARTERY
DISEASE
 Sex-specific analyses suggested - Nephropathy strong CAD risk
factor in men,...
TYPE 2 DIABETES AND CORONARY ARTERY
DISEASE
 Longstanding (>5 years since diagnosis) type 2 DM regarded
as a MI equivalen...
RISK OF CAD EVENTS IN ASYMPTOMATIC
DIABETIC PATIENTS
 In diabetic patients without known CAD, large epidemiologic
studies...
SCREENING FOR ASYMPTOMATIC
MYOCARDIAL ISCHEMIA
 The current ADA (American Diabetic Association)
recommendations include a...
SCREENING FOR ASYMPTOMATIC
MYOCARDIAL ISCHEMIA
 Exercise ECG results are not interpretable in
patients with underlying LB...
SCREENING FOR ASYMPTOMATIC
MYOCARDIAL ISCHEMIA
 Myocardial perfusion imaging used in screening studies for
those patients...
STRESS THALLIUM
SPECT IMAGING
Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to
Evaluate; Curren...
SCREENING FOR ASYMPTOMATIC
MYOCARDIAL ISCHEMIA
 In asymptomatic patients with diabetes, there have been a
number of studi...
SCREENING FOR ASYMPTOMATIC
MYOCARDIAL ISCHEMIA
 These are difficult questions to answer because of the limited
available ...
WHICH SCREENING TEST?
 Because there are no large studies to assist the clinician with
the choice between stress echocard...
DIABETIC PATIENTS AT RISK FOR
ASYMPTOMATIC ISCHEMIA
 The prevalence of asymptomatic ischemia in patients
with diabetes de...
Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to
Evaluate; Curren...
DIABETIC PATIENTS AT RISK FOR
ASYMPTOMATIC ISCHEMIA
 Because widespread screening of diabetic patients for CAD is
not fea...
SILENT MYOCARDIAL ISCHEMIA AND
ANGIOGRAPHIC CHD
 Studies of the prevalence of angiographic CHD in
asymptomatic patients w...
FIGURE 1 VALUE OF NONINVASIVE TESTING FOR MYOCARDIAL ISCHEMIA IN
DETECTING ANGIOGRAPHIC CHD IN UNSELECTED ASYMPTOMATIC SUB...
DIABETIC PATIENTS AT RISK FOR
ASYMPTOMATIC ISCHEMIA
 Autonomic neuropathy (AN) is relatively common in
diabetes, contribu...
LONG-TERM PROGNOSIS ASSOCIATED WITH
ASYMPTOMATIC MYOCARDIAL ISCHEMIA
 There is little information available to address th...
IMPLICATIONS FOR SCREENING
 There is ongoing controversy as to whether patients with
diabetes should be screened with car...
IMPLICATIONS FOR SCREENING
 Critics of generalized screening programs counter with
concerns that screening tests are not ...
CURRENT LIMITATIONS OF
SCREENING
Physical and psychological costs
 The high false-positive rate of existing non invasive ...
CURRENT LIMITATIONS OF
SCREENING
 The detrimental psychological effects - People given false-
positive results have incre...
FINANCIAL AND RESOURCE IMPLICATIONS
 In developing countries Financial concerns are
important as far as output is concern...
POTENTIAL BENEFITS OF EARLIER
DIAGNOSIS
 There have been two small studies suggesting prognostic
benefits from revascular...
POTENTIAL BENEFITS OF EARLIER
DIAGNOSIS
 It was shown that intensive blood sugar control in type 1 DM
can have long-lasti...
SCREENING DOES NOT
REDUCE CARDIAC EVENTS
 Screening for asymptomatic coronary artery disease in
patients with type 2 diab...
SCREENING DOES NOT
REDUCE CARDIAC EVENTS
 The DIAD trial first to prospectively address the issue of
systematic screening...
RECOMMENDATIONS:
CORONARY HEART DISEASE SCREENING
Acording to ADA (American Diabetes Association)
…
 Screening for CAD is...
CONCLUSION
 Over the past 20 years, the greatest advance in CHD therapy in
diabetes has been in disease prevention and no...
Screening for asymptomatic cad in diabetes
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Screening for asymptomatic cad in diabetes

  1. 1. ADD SOME RELATED PICTURE
  2. 2. WORLD BURDEN OF DIABETES
  3. 3. DID YOU KNOW?  Diabetes currently affects 246 million people worldwide and is expected to affect 380 million by 2025.  In 2007, the five countries with the largest numbers of people with diabetes are India (40.9 million), China (39.8 million), the United States (19.2 million), Russia (9.6 million) and Germany (7.4 million).  By 2025, the largest increases in diabetes prevalence will take place in developing countries. Diabetes Atlas, third edition, International Diabetes Federation, 2007. Diabetes and Cardiovascular Disease: Time to Act, International Diabetes Federation, 2001. World Health Organization Diabetes Unit
  4. 4. CARDIOVASCULAR DISEASE (CVD) IN INDIVIDUALS WITH DIABETES  CVD is the major cause of morbidity, mortality for those with diabetes  Common conditions coexisting with type 2 diabetes (e.g., hypertension, dyslipidemia) are clear risk factors for CVD  Diabetes itself confers independent risk  Benefits observed when individual cardiovascular risk factors are controlled to prevent/slow CVD in people with diabetes ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S28.
  5. 5. CARDIOVASCULAR DISEASE (CVD) IN INDIVIDUALS WITH DIABETES  Diabetes reflected by the four-fold greater incidence of CAD.  Early detection of CAD in patients with diabetes may be of paramount importance and could improve outcome.  However, a complicating issue is the silent progression of CAD in patients with diabetes. The disease is frequently already in an advanced state when it becomes clinically manifest.  In addition, recent studies have indicated that conventional coronary risk factors are of limited value for detection of CAD in asymptomatic type 2 diabetes patients.  These observations have raised the question of whether or not asymptomatic patients with diabetes should be screened for CAD. Report by A Joanne D Schuijf et al; Screening for Coronary Artery Disease in Asymptomatic Diabetic Patients; Cardiac Markers, TOUCH BRIEFINGS 2007
  6. 6. TYPE 1 DIABETES AND CORONARY ARTERY DISEASE  The excess coronary artery calcification (CAC) in type 1 diabetes seen in studies from Denver and London.  Major concern - Calcium reflects atherosclerosis or medial wall calcification (i.e., Mockenberg‟s sclerosis) commonly seen in type 1 diabetes.  Overall, the risk of having any CAC appears to be increased by 50%. TREVOR J. ORCHARD et al; Type 1 Diabetes and Coronary Artery Disease; DIABETES CARE, VOLUME 29, NUMBER 11, NOVEMBER 2006
  7. 7. TYPE 1 DIABETES AND CORONARY ARTERY DISEASE  Sex-specific analyses suggested - Nephropathy strong CAD risk factor in men, whereas waist-to-hip ratio and hypertension predominated in women.  Mechanisms account for premature cardiac death in CAD  Subclinical but Advanced coronary atherosclerosis,  Abnormalities in Coronary vasomotor capacity,  Changes in Systolic and Diastolic function, and  Lastly, Life-threatening Arrhythmia  HDL cholesterol inversely predicts CHD mortality in type 1 diabetes, as in the general population, HDL cholesterol levels are generally 10 mg/dl higher in type 1 diabetes  Probably reflecting enhanced lipoprotein lipase and reduced hepatic lipase activity due to systemic insulin administration and altered HDL metabolism. TREVOR J. ORCHARD et al; Type 1 Diabetes and Coronary Artery Disease; DIABETES CARE, VOLUME 29, NUMBER 11, NOVEMBER 2006
  8. 8. TYPE 2 DIABETES AND CORONARY ARTERY DISEASE  Longstanding (>5 years since diagnosis) type 2 DM regarded as a MI equivalent  Because the long-term cardiovascular mortality is similar in diabetic patients without prior myocardial infarction and non-diabetic patients with pre-existing myocardial infarction  Three major studies of tight glycemic control in type 2 DM produced conflicting results on its impact on macro-vascular complications and  One suggested that very tight control (hemoglobin A1c<6.0%) may in fact be detrimental to those with pre-existing cardiovascular disease and long duration of DM. Jamshid Shirani & Vasken Dilsizian; Screening Asymptomatic Patients With Type 2 Diabetes Mellitus for Coronary Artery Disease: Does It Improve Patient Outcome? Curr Cardiol Rep (2010) 12:140–146
  9. 9. RISK OF CAD EVENTS IN ASYMPTOMATIC DIABETIC PATIENTS  In diabetic patients without known CAD, large epidemiologic studies have demonstrated a high incidence of myocardial infarction (11% to 16%), death (8% to 15%), and need for revascularization (41%) over follow-up periods ranging from 3 to 10 years.  In the United Kingdom Prospective Diabetes Study, 12% of subjects with newly diagnosed type 2 diabetes developed CAD (ie, fatal or nonfatal myocardial infarction, or angina with abnormal electrocardiogram [ECG] at rest or after treadmill test) within 10 year. Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  10. 10. SCREENING FOR ASYMPTOMATIC MYOCARDIAL ISCHEMIA  The current ADA (American Diabetic Association) recommendations include a yearly ECG as part of standard clinical practice to evaluate older patients for the presence of CAD.  ADA has suggested that physicians should consider screening with specialized testing in diabetic patients with more than two additional cardiac risk factors  Microalbuminuria, Vascular disease, or Cardiac autonomic neuropathy.  Treadmill exercise ECG is perhaps the least expensive and most widely used screening approach.  In recent studies, the prevalence of myocardial ischemia, as assessed through exercise ECG, in asymptomatic diabetic patients has ranged widely from 9% to 31%. Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  11. 11. SCREENING FOR ASYMPTOMATIC MYOCARDIAL ISCHEMIA  Exercise ECG results are not interpretable in patients with underlying LBBB, ventricular paced rhythms, or left ventricular hypertrophy with marked ST-Twave abnormalities.  Myocardial perfusion imaging or echocardiography, which yield important physiologic information about the cardiac response to stress.  These techniques increase the sensitivity and specificity of exercise testing, and are often used along with pharmacologic stress (eg, adenosine or dobutamine infusions) to provide diagnostic information in patients who are unable to exercise Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  12. 12. SCREENING FOR ASYMPTOMATIC MYOCARDIAL ISCHEMIA  Myocardial perfusion imaging used in screening studies for those patients who are unable to exercise or  As a follow-up evaluation in those who have had a positive exercise ECG rather than in the overall population with diabetes.  In one study of patients unable to exercise, and thus thallium perfusion imaging was performed with dipyridamole, the prevalence of myocardial perfusion abnormalities was 19%.  Recent results from this study indicate that approximately 26% of patients have abnormal stress technetium-sestamibi single photon emission computed tomography (SPECT) imaging. Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  13. 13. STRESS THALLIUM
  14. 14. SPECT IMAGING
  15. 15. Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  16. 16. SCREENING FOR ASYMPTOMATIC MYOCARDIAL ISCHEMIA  In asymptomatic patients with diabetes, there have been a number of studies that have examined the link between baseline SMI and subsequent CHD events.  The weight of evidence now indicates that SMI is related to subsequent CHD events in „high-risk‟ asymptomatic patients with diabetes, and therefore two clinical questions become important.  Firstly, what is the predictive value for a positive or negative test for SMI in relation to subsequent CHD events?  Secondly, what are the relative and absolute CHD risks associated with SMI? Martin K Rutter* and Richard W Nesto; The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes; NATURE CLINICAL PRACTICE ENDOCRINOLOGY & METABOLISM JANUARY 2007 VOL 3 NO 1
  17. 17. SCREENING FOR ASYMPTOMATIC MYOCARDIAL ISCHEMIA  These are difficult questions to answer because of the limited available data, and variation in patient CHD risk, testing methodology and duration of follow-up.  Annualized event rates associated with positive and negativen tests for SMI (Silent Myocardial Ischemia) vary from 2.6% to 35.0%, and from 0% to 9%, respectively; and CHD risk ratios for SMI also show great variability.  Given the large variability in these estimates it is evident that more research is required. Martin K Rutter* and Richard W Nesto; The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes; NATURE CLINICAL PRACTICE ENDOCRINOLOGY & METABOLISM JANUARY 2007 VOL 3 NO 1
  18. 18. WHICH SCREENING TEST?  Because there are no large studies to assist the clinician with the choice between stress echocardiography and myocardial perfusion imaging, in clinical practice that decision should be made based on the local expertise. Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  19. 19. DIABETIC PATIENTS AT RISK FOR ASYMPTOMATIC ISCHEMIA  The prevalence of asymptomatic ischemia in patients with diabetes depends greatly on the specific population examined.  Individuals with type 2 diabetes who may have a higher risk for CAD because of their older age and multiple associated cardiac risk factors.  Type 1 diabetic patients are those with renal insufficiency who are at very high risk for CAD Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  20. 20. Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  21. 21. DIABETIC PATIENTS AT RISK FOR ASYMPTOMATIC ISCHEMIA  Because widespread screening of diabetic patients for CAD is not feasible, there is great interest in identifying patients who are at high enough risk to warrant screening with specialized cardiac testing.  The clinical characteristics identified as predictors of abnormal noninvasive screening tests and abnormal angiography in asymptomatic diabetic patients include  ST-T wave abnormalities at rest; macro- or microalbuminuria; male gender, hypertension, insulin use; retinopathy; smoking; lipoprotein abnormalities; age; peripheral vascular disease; and family history of CAD Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  22. 22. SILENT MYOCARDIAL ISCHEMIA AND ANGIOGRAPHIC CHD  Studies of the prevalence of angiographic CHD in asymptomatic patients with diabetes show a wide variation in prevalence and severity.  Which can be explained by differences in patient selection and testing methodology.  Coronary angiography was recommended if any one of the non invasive tests was positive for SMI. Martin K Rutter* and Richard W Nesto; The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes; NATURE CLINICAL PRACTICE ENDOCRINOLOGY & METABOLISM JANUARY 2007 VOL 3 NO 1
  23. 23. FIGURE 1 VALUE OF NONINVASIVE TESTING FOR MYOCARDIAL ISCHEMIA IN DETECTING ANGIOGRAPHIC CHD IN UNSELECTED ASYMPTOMATIC SUBJECTS WITH DIABETES Rutter MK and Nesto RW (2007) The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes Nat Clin Pract Endocrinol Metab 3: 26–35 doi:10.1038/ncpendmet0352
  24. 24. DIABETIC PATIENTS AT RISK FOR ASYMPTOMATIC ISCHEMIA  Autonomic neuropathy (AN) is relatively common in diabetes, contribute to their lack of anginal symptoms.  The relationship between AN and asymptomatic ischemia has been examined in few studies to date,  In one small study of unselected patients from a diabetes clinic, asymptomatic ischemia was more frequently detected in those with AN (38%) as compared to those without AN (5%).  Milan Study, there was a trend toward AN being more prevalent in diabetic men who had asymptomatic ischemia on exercise perfusion imaging, although similar findings did not appear to be present in diabetic women  Thus, whether there is a clear association of AN neuropathy with asymptomatic ischemia remains uncertain and requires further evaluation. Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  25. 25. LONG-TERM PROGNOSIS ASSOCIATED WITH ASYMPTOMATIC MYOCARDIAL ISCHEMIA  There is little information available to address the degree to which inducible ischemia predicts CAD events in totally asymptomatic patients with diabetes  In a recent small series of asymptomatic patients with either type 1 or type 2 diabetes,  Those with perfusion imaging tended to have an increased incidence of major cardiac events (eg, death, nonfatal myocardial infarction, or revascularization) over 3 to 7 years of follow-up.  Patients with both perfusion abnormalities and AN appeared to be at highest risk.  Further studies need to be done to confirm above associations and to identify a patient population at substantial risk for CAD events. Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  26. 26. IMPLICATIONS FOR SCREENING  There is ongoing controversy as to whether patients with diabetes should be screened with cardiac testing for the presence of asymptomatic CAD or silent ischemia.  Proponents for screening highlight the relatively high incidence of inducible ischemia in asymptomatic type 2 patients and propose that early detection will ensure the use of therapies that may reduce the incidence of myocardial infarction or cardiac death.  However, once a diagnosis of CAD is established, both the patient and health care provider have stronger motivation to pursue intensive therapy, sometimes including β-blockers to prevent ischemia. Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  27. 27. IMPLICATIONS FOR SCREENING  Critics of generalized screening programs counter with concerns that screening tests are not entirely accurate and have yet to conclusively identify those patients at high risk for cardiovascular events.  The argument has been made that screening may in fact only place diabetic patients at increased risk by prompting unnecessary angiography and revascularization procedures. Lawrence H. Young, Powell Jose, BS, and Deborah Chyun; Diagnosis of CAD in Patients with Diabetes: Who to Evaluate; Current Diabetes Reports 2003, 3:19–27
  28. 28. CURRENT LIMITATIONS OF SCREENING Physical and psychological costs  The high false-positive rate of existing non invasive tests is a major concern, especially in low-risk patients, and is caused by factors that include left ventricular hypertrophy, resting electrocardiogram abnormalities and observer error.  This high false-positive rate exposes patients unnecessarily to the risks of angiography  The incidence of important complications from coronary angiography is between 0.5% and 1.8% in the general population Martin K Rutter* and Richard W Nesto; The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes; NATURE CLINICAL PRACTICE ENDOCRINOLOGY & METABOLISM JANUARY 2007 VOL 3 NO 1
  29. 29. CURRENT LIMITATIONS OF SCREENING  The detrimental psychological effects - People given false- positive results have increased anxiety levels that do not rapidly return to normal after further testing confirms the absence of disease.  Another detrimental psychological effect of screening is the „certificate of health‟ effect in which patients who screen negative (the majority) for CHD may in fact be less likely to adhere to healthy lifestyle behaviors Martin K Rutter* and Richard W Nesto; The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes; NATURE CLINICAL PRACTICE ENDOCRINOLOGY & METABOLISM JANUARY 2007 VOL 3 NO 1
  30. 30. FINANCIAL AND RESOURCE IMPLICATIONS  In developing countries Financial concerns are important as far as output is concerned  There are considerable resource implications and financial costs of CHD screening.  These have yet to be adequately assessed by any study. Martin K Rutter* and Richard W Nesto; The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes; NATURE CLINICAL PRACTICE ENDOCRINOLOGY & METABOLISM JANUARY 2007 VOL 3 NO 1
  31. 31. POTENTIAL BENEFITS OF EARLIER DIAGNOSIS  There have been two small studies suggesting prognostic benefits from revascularization in asymptomatic patients with diabetes found to have CHD through screening.  Anti-ischemia therapy could also benefit these patients.  Although there is no hard evidence in these patients, data from studies in the general population make this an attractive hypothesis.  An early diagnosis of CHD could improve compliance and outcome with lifestyle and medical therapy, and knowledge of the presence of CHD might reduce the time to presentation to hospital, in the event of an acute myocardial infarction. Martin K Rutter* and Richard W Nesto; The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes; NATURE CLINICAL PRACTICE ENDOCRINOLOGY & METABOLISM JANUARY 2007 VOL 3 NO 1
  32. 32. POTENTIAL BENEFITS OF EARLIER DIAGNOSIS  It was shown that intensive blood sugar control in type 1 DM can have long-lasting beneficial effects through “metabolic memory” and that 10 years after the initiation of such therapy cardiovascular complications can be reduced by 57%.  Unfortunately, such information is presently less convincing for type 2 DM despite the fact that it represents more than 90% of all cases of diabetes. Jamshid Shirani & Vasken Dilsizian; Screening Asymptomatic Patients With Type 2 Diabetes Mellitus for Coronary Artery Disease: Does It Improve Patient Outcome? Curr Cardiol Rep (2010) 12:140–146
  33. 33. SCREENING DOES NOT REDUCE CARDIAC EVENTS  Screening for asymptomatic coronary artery disease in patients with type 2 diabetes fails to significantly reduce future cardiac events, according to the results of a new study [1].  In light of the findings, the researchers conclude that routine screening for inducible ischemia in asymptomatic patients with diabetes mellitus should not be advocated.  Because what you end up finding is relatively mild, and screening did not make a difference.  Also, the event rate we observed is very low, so the cost of screening to prevent myocardial infarction would be very high. It isn't cost-effective." Young LH, Wackers FJ, Chyun DA, et al. Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes. JAMA 2009; 301: 1547-1555.
  34. 34. SCREENING DOES NOT REDUCE CARDIAC EVENTS  The DIAD trial first to prospectively address the issue of systematic screening for inducible ischemia in an unselected, unbiased, asymptomatic patient population with type 2 diabetes mellitus.  At five years, 70% and 80% of patients were receiving primary- prevention care, and although we can't prove it, it is very likely that this aggressive treatment had something to do with the very low cardiac event rate observed in this study.  The recently published Action to Control Cardiovascular Risk in Diabetes (ACCORD) also reported low event rates, 1.4% per year, which makes DIAD consistent with that trial. Michael O'Riordan; Screening for Asymptomatic CAD in Diabetic Patients Does Not Reduce Cardiac Events; http://www.medscape.com/viewarticle/591148
  35. 35. RECOMMENDATIONS: CORONARY HEART DISEASE SCREENING Acording to ADA (American Diabetes Association) …  Screening for CAD is reviewed in a recently updated consensus statement  However, recent studies concluded that using this approach fails to identify which patients with type 2 diabetes will have silent ischemia on screening tests  Recommendations:  In asymptomatic patients, routine screening for CAD is not recommended, as it does not improve outcomes as long as CVD risk factors are treated (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S32.
  36. 36. CONCLUSION  Over the past 20 years, the greatest advance in CHD therapy in diabetes has been in disease prevention and not in screening.  Recent research suggests the possibility that there are significant numbers of high-risk asymptomatic patients with diabetes and undiagnosed CHD who could in fact benefit from anti-ischemia therapy and revascularization.  However, with the recent advances in medical therapy, and the uncertain benefits of screening, the AHA has strongly discouraged this practice, except in limited clinical situations, such as before major surgery Martin K Rutter* and Richard W Nesto; The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes; NATURE CLINICAL PRACTICE ENDOCRINOLOGY & METABOLISM JANUARY 2007 VOL 3 NO 1

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