Asia Oceania Journal of Nuclear Medicine and Biology

Asia Oceania Journal of Nuclear Medicine and Biology

Clinical value and severity of myocardial perfusion defects in asymptomatic diabetic patients with negative or weakly positive exercise treadmill test

Document Type : Original Article

Authors
Seyed Rasoul Zakavi 1
Mehdi Taherpour 2
Zohreh Moossavi 3
Ramin Sadeghi 1
Vahidreza Dabbagh Kakhki 1
Haleh Rokni 3
1 Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
2 Cardiology Department, Razavi Hospital, Mashhad, Iran
3 Endocrinology and Metabolism Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
10.7508/aojnmb.2013.01.004
Abstract
Objective(s): Although coronary artery disease (CAD) is the leading cause of death in type 2 diabetic patients, it is frequently asymptomatic. Myocardial perfusion imaging (MPI) is reported to show ischemia in a significant number of asymptomatic diabetic patients. We studied the prevalence and severity of myocardial perfusion defects in asymptomatic diabetic patients and its clinical impact.
Methods and patients: One hundred thirty consecutive asymptomatic patients, aged 35-65 years with type 2 diabetes mellitus and with no history of CAD and no cardiac symptoms were recruited in the study. Echocardiography, electrocardiography (ECG), routine laboratory tests and exercise treadmill test (ETT) were performed and patients with weakly positive or negative ETT underwent Dipyridamole MPI. Patients with positive ETT were referred to coronary angiography. Patients were followed for at least 17 months (mean 21.7 months) and any cardiac event was recorded.
Results: We studied 81 female and 49 male patients with mean age of 51.8 years. Negative, weakly positive and positive ETT result was noted in 74.3%, 15% and 10.7% respectively. 75% of patients with positive ETT had coronary artery disease in angiography. Gated myocardial perfusion SPECT was done in 106 patients. MPI showed reversible defect in 26.9% of the patients with a mean summed stress score of 3.3±1.8. Follow up completed in 112 patients and only one patient with abnormal MPI underwent coronary angiography followed by PTCA. No cardiac death, MI, UA or hospital admission occurred among our patients during follow up (17-26 months). Mean stress end diastolic volume (EDV) was significantly higher in patients with reversible defect compared to patients without reversible defect based on MPI findings (62.0±31.6 Vs 48.5±18.4 ml, P=0.04). Blood glucose and HA1c were significantly higher in patients with ischemia compared to patients without ischemia (P<0.05). Meanwhile the ratio of TG to HDL was 6.06±3.2 in ischemic patients compared to 4.8±2.3 in normal subjects (P=0.03).
Conclusion: Reversible defects are commonly seen in myocardial perfusion SPECT in asymptomatic diabetic patients and are mild in severity and not associated with adverse cardiac events. Routine approach for detection of CAD beginning with ETT seems to be appropriate in these patients.
Keywords
Coronary Artery Disease
Diabetes Mellitus
Gated myocardial perfusion SPECT
Silent Ischemia
  1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004 May;27(5):1047-53.
  2. Young LH, Wackers FJ, Chyun DA, Davey JA, Barrett EJ, Taillefer R, et al. Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study: a randomized controlled trial. Jama. 2009 Apr 15;301(15):1547-55.
  3. Jouven X, Lemaitre RN, Rea TD, Sotoodehnia N, Empana JP, Siscovick DS. Diabetes, glucose level, and risk of sudden cardiac death. Eur Heart J. 2005 Oct;26(20):2142-7.
  4. Bax JJ, Young LH, Frye RL, Bonow RO, Steinberg HO, Barrett EJ. Screening for coronary artery disease in patients with diabetes. Diabetes Care. 2007 Oct;30(10):2729-36.
  5. Fateh-Moghadam S, Reuter T, Htun P, Plockinger U, Dietz R, Bocksch W. Stressechocardiography for risk stratification of asymptomatic patients with type 2 diabetes mellitus. Int J Cardiol. 2009 Jan 9;131(2):288-90.
  6. Scholte AJ, Schuijf JD, Kharagjitsingh AV, Jukema JW, Pundziute G, van der Wall EE, et al. Prevalence of coronary artery disease and plaque morphology assessed by multi-slice computed tomography coronary angiography and calcium scoring in asymptomatic patients with type 2 diabetes. Heart. 2008 Mar;94(3):290-5.
  7. Wackers FJ, Young LH, Inzucchi SE, Chyun DA, Davey JA, Barrett EJ, et al. Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study. Diabetes Care. 2004 Aug;27(8):1954-61.
  8. Bax JJ, Bonow RO, Tschope D, Inzucchi SE, Barrett E. The potential of myocardial perfusion scintigraphy for risk stratification of asymptomatic patients with type 2 diabetes. J Am Coll Cardiol. 2006 Aug 15;48(4):754-60.
  9. Feringa HH, Karagiannis SE, Vidakovic R, Elhendy A, ten Cate FJ, Noordzij PG, et al. The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery. Coron Artery Dis. 2007 Nov;18(7):571-6.
  10. Zellweger MJ, Hachamovitch R, Kang X, Hayes SW, Friedman JD, Germano G, et al. Prognostic relevance of symptoms versus objective evidence of coronary artery disease in diabetic patients. Eur Heart J. 2004 Apr;25(7):543-50.
  11. Zellweger MJ, Hachamovitch R, Kang X, Hayes SW, Friedman JD, Germano G, et al. Threshold, incidence, and predictors of prognostically high-risk silent ischemia in asymptomatic patients without prior diagnosis of coronary artery disease. J Nucl Cardiol. 2009 Mar-Apr;16(2):193-200.
  12. Hurni CA, Perret S, Monbaron D, Gaillard R, Ruiz J. Coronary artery disease screening in diabetic patients: how good is guideline adherence? Swiss Med Wkly. 2007 Apr 7;137(13-14):199-204.
  13. Ryden L, Standl E, Bartnik M, Van den Berghe G, Betteridge J, de Boer MJ, et al. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). Eur Heart J. 2007 Jan;28(1):88-136.
  14. Smith SC, Jr., Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006 May 16;113(19):2363-72.
  15. Valensi P. [Silent coronary artery disease in diabetic patients. New guidelines]. Rev Med Liege. 2005 May-Jun;60(5-6):531-5.
  16. Beishuizen ED, Jukema JW, Tamsma JT, van de Ree MA, van der Vijver JC, Putter H, et al. No effect of statin therapy on silent myocardial ischemia in patients with type 2 diabetes without manifest cardiovascular disease. Diabetes Care. 2005 Jul;28(7):1675-9.
  17. Almeda FQ, Kason TT, Nathan S, Kavinsky CJ. Silent myocardial ischemia: concepts and controversies. Am J Med. 2004 Jan 15;116(2):112-8.
  18. Rogers WJ, Frederick PD, Stoehr E, Canto JG, Ornato JP, Gibson CM, et al. Trends in presenting characteristics and hospital mortality among patients with ST elevation and non-ST elevation myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J. 2008 Dec;156(6):1026-34.
  19. Cortigiani L, Bigi R, Sicari R, Landi P, Bovenzi F, Picano E. Prognostic value of pharmacological stress echocardiography in diabetic and nondiabetic patients with known or suspected coronary artery disease. J Am Coll Cardiol. 2006 Feb 7;47(3):605-10.
  20. Prior JO, Monbaron D, Koehli M, Calcagni ML, Ruiz J, Bischof Delaloye A. Prevalence of symptomatic and silent stress-induced perfusion defects in diabetic patients with suspected coronary artery disease referred for myocardial perfusion scintigraphy. Eur J Nucl Med Mol Imaging. 2005 Jan;32(1):60-9.
  21. Smanio PE, Carvalho AC, Tebexreni AS, Thom A, Rodrigues F, Meneghelo R, et al. Coronary artery disease in asymptomatic type-2 diabetic women. A comparative study between exercise test, cardiopulmonary exercise test, and dipyridamole myocardial perfusion scintigraphy in the identification of ischemia. Arq Bras Cardiol. 2007 Nov;89(5):263-9, 90-7.
  22. Choi EK, Koo BK, Kim HS, Cho YM, Kang HJ, Cho YS, et al. Prognostic significance of asymptomatic coronary artery disease in patients with diabetes and need for early revascularization therapy. Diabet Med. 2007 Sep;24(9):1003-11.
  23. Barthelemy O, Le Feuvre C, Timsit J. Silent myocardial ischemia screening in patients with diabetes mellitus. Arq Bras Endocrinol Metabol. 2007 Mar;51(2):285-93.
  24. Sozzi FB, Elhendy A, Rizzello V, Biagini E, van Domburg RT, Schinkel AF, et al. Prognostic significance of myocardial ischemia during dobutamine stress echocardiography in asymptomatic patients with diabetes mellitus and no prior history of coronary events. Am J Cardiol. 2007 May 1;99(9):1193-5.
  25. Scholte AJ, Schuijf JD, Kharagjitsingh AV, Dibbets-Schneider P, Stokkel MP, van der Wall EE, et al. Prevalence and predictors of an abnormal stress myocardial perfusion study in asymptomatic patients with type 2 diabetes mellitus. Eur J Nucl Med Mol Imaging. 2009 Apr;36(4):567-75.
  26. Chareonthaitawee P, Sorajja P, Rajagopalan N, Miller TD, Hodge DO, Frye RL, et al. Prevalence and prognosis of left ventricular systolic dysfunction in asymptomatic diabetic patients without known coronary artery disease referred for stress single-photon emission computed tomography and assessment of left ventricular function. Am Heart J. 2007 Sep;154(3):567-74.
  27. Bertoni AG, Goff DC, Jr., D’Agostino RB, Jr., Liu K, Hundley WG, Lima JA, et al. Diabetic cardiomyopathy and subclinical cardiovascular disease: the Multi-Ethnic Study of Atherosclerosis (MESA). Diabetes Care. 2006 Mar;29(3):588-94.
  28. Bittner V, Johnson BD, Zineh I, Rogers WJ, Vido D, Marroquin OC, et al. The triglyceride/high-density lipoprotein cholesterol ratio predicts all-cause mortality in women with suspected myocardial ischemia: a report from the Women’s Ischemia Syndrome Evaluation (WISE). Am Heart J. 2009 Mar;157(3):548-55.
  29. Tseng CH. Waist-to-height ratio and coronary artery disease in Taiwanese type 2 diabetic patients. Obesity (Silver Spring). 2008 Dec;16(12):2754-9.
  30. Conway B, Miller RG, Costacou T, Fried L, Kelsey S, Evans RW, et al. Double-edged relationship between adiposity and coronary artery calcification in type 1 diabetes. Diab Vasc Dis Res. 2007 Dec;4(4):332-9.
  31. Yasuda T, Matsuhisa M, Fujiki N, Sakamoto F, Tsuji M, Fujisawa N, et al. Is central obesity a good predictor of carotid atherosclerosis in Japanese type 2 diabetes with metabolic syndrome? Endocr J. 2007 Dec;54(5):695-702.
  32. Rutter MK NR. The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes. Nat Clin Pract Endocrinol Metab. 2007;3(1):26-35.
  33. Miller TD, Redberg RF, Wackers FJ. Screening asymptomatic diabetic patients for coronary artery disease: why not? J Am Coll Cardiol. 2006 Aug 15;48(4):761-4.
  34. Hayashino Y, Shimbo T, Tsujii S, Ishii H, Kondo H, Nakamura T, et al. Cost-effectiveness of coronary artery disease screening in asymptomatic patients with type 2 diabetes and other atherogenic risk factors in Japan: factors influencing on international application of evidence-based guidelines. Int J Cardiol. 2007 May 16;118(1):88-96.
  35. Scognamiglio R, Negut C, Ramondo A, Tiengo A, Avogaro A. Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus. J Am Coll Cardiol. 2006 Jan 3;47(1):65-71.
  36. Rakhit DJ, Downey M, Jeffries L, Moir S, Prins JB, Marwick TH. Screening for coronary artery disease in patients with diabetes: a Bayesian strategy of clinical risk evaluation and exercise echocardiography. Am Heart J. 2005 Nov;150(5):1074-80.
  37. Sorajja P, Chareonthaitawee P, Rajagopalan N, Miller TD, Frye RL, Hodge DO, et al. Improved survival in asymptomatic diabetic patients with high-risk SPECT imaging treated with coronary artery bypass grafting. Circulation. 2005 Aug 30;112(9 Suppl):I311-6.