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Should patients with type 2 diabetes asymptomatic for coronary artery disease undergo testing for myocardial ischemia?

Nature Clinical Practice Cardiovascular Medicine volume 2, pages 492–493 (2005)Cite this article

A marked increase in the incidence of impaired glucose tolerance and the subsequent development of diabetes has resulted in a worldwide health-care crisis.1 The prevalence of type 2 diabetes has increased by more than 61% since 1990,2 due mainly to more-sedentary lifestyles, the ensuing obesity, and the rising age of patients in the US. More than 75% of diabetes-related hospitalizations are caused by atherosclerosis and its complications.3 Furthermore, severe proximal and distal coronary artery disease (CAD) and coronary artery plaque alterations, including inflammation and thrombosis, are more-frequently observed on coronary arteriography and intravascular ultrasound in individuals with diabetes than in those without.4

Risk factors for the development of cardiovascular disease in patients with diabetes include obesity, cigarette smoking, systemic hypertension, dyslipidemia, albuminuria and chronic renal disease. Glycemia control lowers the risk of vascular diseases, by reducing the production of advanced glycosylation end-products,5 the accumulation of which is thought to promote atherosclerosis.6 The atherosclerosis-promoting effects of advanced glycosylation end-products are listed in Supplementary Box 1 online. Progression from impaired glucose tolerance or the metabolic syndrome to overt diabetes can be slowed or even prevented by lifestyle changes and pharmacotherapy. Weight reduction and an exercise program should be instigated early, and the use of angiotensin-converting-enzyme inhibitors, statins and several oral hypoglycemic agents (such as thiazolidinediones and metformin) can be useful.6 Nevertheless, more than 25% of patients with diabetes have severe myocardial ischemia, myocardial infarction or both, without chest pain or chest discomfort.7 This finding raises an important question: should asymptomatic patients with type 2 diabetes be investigated for CAD and, if present, how should they be treated?

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  1. a Professor of Medicine at the Division of Cardiology at the University of Texas Health Science Center, San Antonio, TX, USA

    Robert A O'Rourke

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  1. Robert A O'Rourke
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Correspondence to Robert A O'Rourke.

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The author declares no competing financial interests.

Supplementary information

Supplementary Box 1

Atherosclerosis-promoting effects of advanced glycosylation end-products

Supplementary Box 2

Methods of diagnosing coronary artery disease in asymptomatic patients with diabetes

Supplementary Box 3

Reasons for using noninvasive testing for assessing coronary artery disease in patients who have diabetes with no chest pain

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O'Rourke, R. Should patients with type 2 diabetes asymptomatic for coronary artery disease undergo testing for myocardial ischemia?. Nat Rev Cardiol 2, 492–493 (2005). https://doi.org/10.1038/ncpcardio0326

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