SILENT ISCHEMIA IN DIABETES NOT AS COMMON NOR THREATENING AS THOUGHT people with diabetes. with a heart attack their diabetes sometimes undiagnosed …
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SILENT ISCHEMIA IN DIABETES NOT AS COMMON NOR THREATENING AS THOUGHT
Favorable 5-Year Outcome for Asymptomatic People with Type 2 Without Evidence of Coronary Artery Disease Expensive Screening Not Needed When Standard Clinical Care and Follow-Up Attentive
San Francisco, CA June 8, 2008 Results of a nearly five-year study of more than 1,100 older adults with type 2 diabetes a group that is at risk for heart attacks or sudden death may let them breathe a little easier, according to a report presented here today at the American Diabetes Associations 68th Annual Scientific Sessions We found that silent myocardial ischemia restriction of blood flow to the heart occurred in only 22 of the asymptomatic adults with type 2 diabetes that we screened, a far lower percentage than expected, said Frans J Wackers, MD, PhD, Professor Emeritus, Diagnostic Radiology and Medicine, Yale University School of Medicine, in a recent interview He led the Detection of Ischemia in
Asymptomatic Diabetics DIAD study, which was conducted to assess the prevalence of such ischemia and discern whether expensive coronary artery disease screening used in the study should be offered to all people with type 2 diabetes His conclusion: its not justified Over the course of the study, all participants continued to be seen by their own physicians, and the physicians of 30 of the unscreened control group independently found reason to recommend various diagnostic and treatment procedures, such as stress testing, cardiac catheterization, angioplasty, and bypass surgery, to their patients, said Dr Wackers Since these control patients likely had an equal prevalence of ischemia to those who were screened, standard clinical care and attentive follow-up appear to be sufficient to detect those at risk and in need of intensive cardiologic care After nearly five years, there was essentially no difference between the groups with the overall cumulative rate of cardiac events only 28, which was much lower than anyone had expected - more -
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DIAD Page 2 Silent Ischemia According to the National Institutes of Health, heart disease and stroke account for about 65 of deaths in people with diabetes Adults with diabetes have heart disease death rates about 2 to 4 times higher than those without diabetes Too many people arrive at hospitals with a heart attack their diabetes sometimes undiagnosed and with no prior warning that they have a cardiac problem Some studies have shown that a diabetes diagnosis as an adult yields the same risk for a future cardiovascular event as a person without diabetes who has previously had one heart attack The normal warning sign of a shortage of blood flow to the heart is the chest pain called angina However, due to a common form of nerve damage in people with diabetes called neuropathy, that warning pain is often not felt or may only be experienced at such a low level that it is not perceived as a warning How widespread such silent myocardial ischemia is in people with diabetes
has long been debated, with some studies suggesting the figure was as high as 60 However, other researchers believed that studies showing high estimates were contaminated because they included people who went to the hospital for problems related to the heart DIAD Design DIAD was designed to avoid problems seen in prior studies Working with 14 diabetes clinics in the US and Canada, study investigators recruited 1,123 adults with type 2 diabetes who had no cardiac symptoms, no previously diagnosed coronary artery disease, and normal electrocardiograms ECGs Participants were aged 55 to 75 years at the outset, with a mean diabetes duration of 87 years Patients were randomly assigned to either the screening or control no screening group The Screening The screening test used in the DIAD study was adenosine stress myocardial perfusion imaging MPI, a standard test cardiologists perform to evaluate patients at high risk for coronary disease The stress is not induced by walking on a treadmill, but by a medication called adenosine Adenosine does not increase your heart rate Rather, it dilates blood vessels leading into the heart, increasing blood flow, therefore simulating exercise for the
patients - more National Office 1701 North Beauregard Street Alexandria, VA 22311 Tel: 703-549-1500 Diabetes Information call 1-800-DIABETES 1-800-342-2383 online wwwdiabetesorg
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tefully accepts gifts through your will
The Mission of the American Diabetes Association is to prevent and cure diabetes and to improve the lives of all people affected by diabetes
DIAD Page 3
The patient is given a 4-minute intravenous infusion with a radioisotope tag If any area of the heart does not display increased blood flow, as it should under stress, then it will have less radioisotope displayed, which is an indicator of a defect Three-dimensional radionuclide SPECT single photon emission computed tomography imaging of the heart, which takes about 45 minutes, enables the cardiologist to evaluate the significance of any defect All of this is done with the patient comfortably lying down While this is a standard test, it requires an experienced person to interpret the results, and the test can cost up to several thousand dollars, depending on the area of the country where it is performed Detailed Findings Of those screened at the outset, 22 had silent myocardial ischemia, of
which only 6 of the defects were considered severe When we sent the results to their physicians, we were afraid that all of these patients would be referred to cardiologists, which would damage the results of our study, said Dr Wackers We honestly reported that we did not know what the findings meant, and we did not recommend treatment The result was that only a small number of the ischemic patients were referred by their physicians for cardiac evaluation; some were found to have coronary artery disease and some went on to have bypass surgery All DIAD study participants were called every six months to check on their health, ie to determine whether they had developed any symptoms of cardiac problems, such as congestive heart failure, heart attack, or death Over 48 years, there was essentially no difference between the two groups, reported Dr Wackers Screening did not improve outcomes The rate of cardiac events was a half percent per year, much lower than anyone had been expecting, for a cumulative rate of cardiac events of 28 He believes this low rate is in small measure due to the cardiac procedures undertaken by a small number of ischemic patients both among the screened and the
controls; 7 in both groups had bypass surgery Nonetheless, the overall results bode well - more -
National Office 1701 North Beauregard Street Alexandria, VA 22311 Tel: 703-549-1500
Diabetes Information call 1-800-DIABETES 1-800-342-2383 online wwwdiabetesorg
The Association gratefully accepts gifts through your will
The Mission of the American Diabetes Association is to prevent and cure diabetes and to improve the lives of all people affected by diabetes
DIAD Page 4
However, over the course of the study, the percentage of participants who were being treated by their physicians with aspirin, statins, and anti-hypertensive medications rose from 40 at the outset of the study to 75 at the close I think that rather than the surgical interventions, this optimized treatment explains why both groups did so well Therefore, asymptomatic people with diabetes who do not have evidence of coronary artery disease have favorable five-year outcomes, he concludes The situation is not as bad as we thought, and we dont have to spend millions of dollars to screen everyone with diabetes with stress adenosine MPI, but they do have to be followed closely, with diagnosis and treatment done when any
symptoms or other indications arise Nearly 21 million Americans have diabetes, a group of serious diseases characterized by high blood glucose levels that result from defects in the bodys ability to produce and/or use insulin Diabetes can lead to severely debilitating or fatal complications, such as heart disease, blindness, kidney disease, and amputation It is the fifth leading cause of death by disease in the US Type 2 diabetes involves insulin resistance the bodys inability to properly use its own insulin Type 2 occurs mainly in adults who are overweight and ages 40 and older The American Diabetes Association is the nations leading voluntary health organization supporting diabetes research, information and advocacy Founded in 1940, the Association has offices in every region of the country, providing services to hundreds of communities For more information, please call the American Diabetes Association at 1-800-DIABETES 1-800-342-2383 or visit wwwdiabetesorg Information from both these sources is available in English and Spanish Abstract 169-OR NOTE TO EDITOR: Visit http://wwwdiabetesorg/adablog to read blog posts from the Associations Scientific Sessions from former USA Today
reporter, Anita Manning
National Office 1701 North Beauregard Street Alexandria, VA 22311 Tel: 703-549-1500
Diabetes Information call 1-800-DIABETES 1-800-342-2383 online wwwdiabetesorg
The Association gratefully accepts gifts through your will
The Mission of the American Diabetes Association is to prevent and cure diabetes and to improve the lives of all people affected by diabetes
