Coronary artery disease (CAD) is a major cause of morbidity, mortality, and medical costs in diabetes. Over the past 2 decades, there has been a greater recognition of the prevalence and impact of CAD among patients with diabetes. The benefit of both primary and secondary cardiovascular risk factor modification on cardiac outcomes has been proven in studies, and these results are driving guidelines for care in diabetes.

Early Diagnosis is Critical

According to published data, an early diagnosis of CAD is helpful in preventing progression and clinical events in diabetes. Although current recommendations do not recommend that specialized CAD screening be conducted in patients for those at high risk for complications, screening should be considered. For patients with diabetes who are found to have asymptomatic CAD, it’s imperative for clinicians to focus on risk factor burden, baseline electrocardiogram (ECG) results, and whether there is clinical evidence of vascular disease at other sites. The high prevalence of adverse cardiac outcomes in patients with diabetes underscores the need for considering diagnostic testing in the high-risk population.

The goal of screening patients with diabetes for advanced asymptomatic CAD is motivated by the identification of those with high cardiac risk whose outcomes might be improved through more aggressive risk factor modification, medical surveillance, or even revascularization of their CAD. However, clinical factors that confer risk for adverse cardiac outcomes do not always predict which patients will have abnormal screening tests. Furthermore, negative screenings in patients with diabetes do not uniformly confer a benign prognosis. Tests that detect ischemia or assess atherosclerotic burden don’t always identify patients at risk for plaque rupture and thrombosis. Considering these facts, it behooves clinicians to classify CAD risk and provide treatments accordingly.

Classifying Risk

Patients with clinical CAD can be classified as low, intermediate, or high risk. Most asymptomatic patients with type 2 diabetes fall into the intermediate cardiac risk category, but there is also a range of risk that would be helpful to further understand. In the absence of symptomatic CAD, clinical features that can help physicians identify patients with increased risk for heart attack or cardiac death include evidence of other atherosclerotic, vascular, or renal disease; abnormal resting ECGs; and diabetes complications (eg, autonomic neuropathy, age, sex, and traditional and novel cardiac risk factors). Although these factors might not specifically predict the presence of inducible ischemia, they should still be considered carefully for identifying patients who are at risk for cardiovascular events.

More Data Wanted

Evidence has accumulated regarding newer CAD diagnostic modalities, including CT angiography, coronary artery calcium scoring, and cardiac MRI, and these modalities are being implemented more frequently in strategies for diagnosing and staging CAD. However, data that could provide robust “evidence-based” recommendations for CAD testing in patients with diabetes are not yet available. Simply identifying specific metabolic syndrome criteria isn’t enough. One danger of focusing on diagnosing underlying metabolic syndrome is that that those who do not meet the criteria may not get appropriate treatment. All risk factors, irrespective of the metabolic syndrome (eg, dyslipidemia, hypertension, smoking, obesity, and physical inactivity), are operative in diabetes and mandate rigorous intervention.

Until more data emerge, physicians should strive to conduct comprehensive risk factor assessments, especially family history when C-reactive protein is elevated. Physicians should also consider coronary calcium assessments and other diagnostic markers when evaluating patients with diabetes who are asymptomatic. These findings should then be linked with current guideline recommendations for managing blood pressure, lipids, smoking, and obesity. Addressing all of the CAD risk components in patients with diabetes may enable physicians to intervene with appropriate intensity and vigor, and ultimately improve long-term outcomes.

Trevor J. Orchard, MD, MSc, FAHA, has indicated to Physician’s Weekly that he has received consulting fees from AstraZeneca, Eli Lilly, and Takeda. He has also received grant support from VeraLight and has an equity interest in Bristol-Myers Squibb.

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