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Screening
patients with Diabetes for CAD does not
significantly reduce risk of Cardiac Events
Newswise — Screening for coronary artery disease in
patients with type 2 diabetes did not result
in a significant reduction in the rate of
heart attacks or cardiac death compared to
patients who were not screened, according to
a study in the April 15 issue of JAMA,
a theme issue on diabetes.
Frans J. Th. Wackers, M.D., Ph.D., of the Yale University
School of Medicine, New Haven, Conn.,
presented the findings of the study at a
JAMA media briefing at the National Press
Club in Washington, D.C.
Almost 200 million people worldwide have type 2 diabetes.
“Coronary artery disease (CAD) is a major health concern
and the leading cause of death in
individuals with type 2 diabetes.
"CAD is often asymptomatic [having no symptoms] in these
patients until the onset of myocardial
infarction [heart attack] or sudden cardiac
death,” the authors write.
There has been substantial interest in the early detection
of asymptomatic CAD by screening of patients
with type 2 diabetes.
However, the potential of routine screening to alter
treatment and to prevent cardiac events in
persons without clinically apparent CAD is
largely unknown, according to background
information in the article.
Dr. Wackers and colleagues of the Detection of Ischemia in
Asymptomatic Diabetics (DIAD) study group
tested prospectively whether systematic
screening for CAD would identify higher-risk
individuals and beneficially affect their
risk of heart attack or cardiac death.
In the trial, that included 1,123 participants with type 2
diabetes and no symptoms of CAD, patients
were randomly assigned to be screened (n =
561) for CAD with the imaging method of
adenosine-stress radionuclide myocardial
perfusion imaging (MPI), or not be screened
(n = 562). The average follow-up was 4.8
years.
The overall cumulative 5-year cardiac event rate was 2.9
percent and averaged 0.6 percent per year,
lower than anticipated.
The researchers found that when analyzed according to
randomization, there were 15 events (7
nonfatal heart attacks; 8 cardiac deaths;
2.7 percent ) in the screening group vs. 17
events (10 nonfatal heart attacks; 7 cardiac
deaths; 3.0 percent) in the no-screening
group. Of those in the screened group, 409
participants (78 percent) with normal
results and 50 (10 percent) with small MPI
defects had lower event rates than the 33
with moderate or large MPI defects; 0.4
percent per year vs. 2.4 percent per year.
Coronary angiography was performed within 120 days after
screening in 4.4 percent of 561
participants, including in 15 percent of 33
with moderate or large defects.
In comparison, only 3 (0.5 percent) of 562 participants in
the no-screening group underwent angiography
within 120 days after randomization.
The overall rate of coronary revascularization was low in
both groups: 5.5 percent in the screened
group and 7.8 percent in the unscreened
group.
During the course of the study there was a significant and
equivalent increase in primary medical
prevention with aspirin, statins and
angiotension-converting enzyme (ACE)
inhibitors in both groups.
“The strategy of routine screening for CAD in patients with
type 2 diabetes is based on the premise that
testing could accurately identify a
significant number of individuals at
particularly high risk and lead to various
interventions that prevent cardiac events.
However, the results of the DIAD study would
appear to refute this notion,” the authors
write. “… participants had a low cardiac
event rate and the identification of
participants with abnormal screening results
did not serve to eliminate their risk over 5
years of follow-up.”
“However, rather than viewing this study as a negative
screening study, clinicians might consider
the results as a positive message: patients
with type 2 diabetes without symptoms to
suggest CAD, receiving contemporary medical
care, close follow-up, and appropriate
diagnostic evaluation for symptoms of
ischemia have relatively favorable outcomes
in the current era.”
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