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The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes

Abstract

Aggressive medical therapy can be justified in most patients with diabetes, but there may be some higher-risk asymptomatic patients who could benefit from revascularization and/or medical therapy for myocardial ischemia. Silent myocardial ischemia (SMI) might be used to identify these high-risk individuals. In this Review we define SMI as objective evidence of ischemia from any noninvasive test occurring in an asymptomatic patient. We outline what is known about asymptomatic coronary heart disease (CHD) in diabetes and how this relates to SMI. We examine how SMI predicts angiographic CHD and CHD events, and we describe the changing role of CHD screening as reflected by various guidelines. We identify the recent research suggesting that there may be substantial numbers of high-risk asymptomatic patients who have diabetes with undiagnosed CHD and who could benefit from more-active intervention; however, with the recent advances in medical therapy, and the uncertain benefits of screening, current guidelines strongly discourage this practice, except in limited clinical situations, such as before major surgery. Carefully conducted clinical trails using state-of-the-art investigations and therapy in well-characterized patients with diabetes are urgently required to inform physicians on when and how to intervene.

Key Points

  • Coronary heart disease (CHD) is the leading cause of death in patients with diabetes and is often asymptomatic

  • Silent myocardial ischemia (SMI) can help identify patients with diabetes who have angiographic CHD and who are at high risk for CHD events

  • Aggressive medical therapy can be justified in the majority of patients with diabetes regardless of the presence of SMI

  • In the future, CHD screening using SMI might be used to identify asymptomatic patients with diabetes who could benefit from anti-ischemia medication and/or revascularization

  • At the time of writing, however, CHD screening of asymptomatic patients with diabetes is not justified because there is insufficient evidence of clinical benefit

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Figure 1: Value of noninvasive testing for myocardial ischemia in detecting angiographic CHD in unselected asymptomatic subjects with diabetes.

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Correspondence to Martin K Rutter.

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Rutter, M., Nesto, R. The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes. Nat Rev Endocrinol 3, 26–35 (2007). https://doi.org/10.1038/ncpendmet0352

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