Abstract
Purpose
Silent myocardial ischaemia—as evaluated by stress-induced perfusion defects on myocardial perfusion scintigraphy (MPS) in patients without a history of chest pain—is frequent in diabetes and is associated with increased rates of cardiovascular events. Its prevalence has been determined in asymptomatic diabetic patients, but remains largely unknown in diabetic patients with suspected coronary artery disease (CAD) in the clinical setting. In this study we therefore sought (a) to determine the prevalence of symptomatic and silent perfusion defects in diabetic patients with suspected CAD and (b) to characterise the eventual predictors of abnormal perfusion.
Methods
The patient population comprised 133 consecutive diabetic patients with suspected CAD who had been referred for MPS. Studies were performed with exercise (41%) or pharmacological stress testing (1-day protocol, 99mTc-sestamibi, 201Tl or both). We used semi-quantitative analysis (20-segment polar maps) to derive the summed stress score (SSS) and the summed difference score (SDS).
Results
Abnormal MPS (SSS≥4) was observed in 49 (37%) patients (SSS=4.9±8.4, SDS=2.4±4.7), reversible perfusion defects (SDS≥2) in 40 (30%) patients [SSS=13.3±10.9; SDS=8.0±5.6; 20% moderate to severe (SDS>4), 7% multivessel] and fixed defects in 21 (16%) patients. Results were comparable between patients with and patients without a history of chest pain. Of 75 patients without a history of chest pain, 23 (31%, 95% CI=21–42%) presented reversible defects (SSS=13.9±11.3; SDS=7.4±1.2), indicative of silent ischaemia. Reversible defects were associated with inducible ST segment depression during MPS stress [odds ratio (OR)=3.2, p<0.01). Fixed defects were associated with erectile dysfunction in males (OR=3.7, p=0.02) and lower aspirin use (OR=0.25, p=0.02).
Conclusion
Silent stress-induced perfusion defects occurred in 31% of the patients, a rate similar to that in patients with a history of chest pain. MPS could identify these patients with a potentially increased risk of cardiovascular events.
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References
King H, Aubert RE, Herman WH. Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections. Diabetes Care 1998;21:1414–31.
Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the multiple risk factor intervention trial. Diabetes Care 1993;16:434–44.
Klein J, Chao SY, Berman DS, Rozanski A. Is ‘silent’ myocardial ischemia really as severe as symptomatic ischemia? The analytical effect of patient selection biases. Circulation 1994;89:1958–66.
Fowler PB. The UK prospective diabetes study. Lancet 1998;352:1933; author reply 1934.
Passa P, Drouin P, Issa-Sayegh M, Blasco A, Masquet C, Monassier JP, Paillole C. Coronary disease and diabetes. Diabetes Metab 1995;21:446–51.
Consensus development conference on the diagnosis of coronary heart disease in people with diabetes: 10–11 February 1998, Miami, Florida. American Diabetes Association. Diabetes Care 1998;21:1551–9.
Underwood SR, Anagnostopoulos C, Cerqueira M, Ell PJ, Flint EJ, Harbinson M, et al. Myocardial perfusion scintigraphy: the evidence. A consensus conference organised by the British Cardiac Society, the British Nuclear Cardiology Society and the British Nuclear Medicine Society, endorsed by the Royal College of Physicians of London and the Royal College of Radiologists. Eur J Nucl Med Mol Imaging 2004;31:261–91. DOI 10.1007/s00259-003-1344-5.
Kang X, Berman DS, Lewin HC, Cohen I, Friedman JD, Germano G, et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography in patients with diabetes mellitus. Am Heart J 1999;138:1025–32.
Giri S, Shaw LJ, Murthy DR, Travin MI, Miller DD, Hachamovitch R, et al. Impact of diabetes on the risk stratification using stress single-photon emission computed tomography myocardial perfusion imaging in patients with symptoms suggestive of coronary artery disease. Circulation 2002;105:32–40.
Koistinen MJ. Prevalence of asymptomatic myocardial ischaemia in diabetic subjects. Br Med J 1990;301:92–5.
Milan Study on Atherosclerosis and Diabetes (MiSAD) Group. Prevalence of unrecognized silent myocardial ischemia and its association with atherosclerotic risk factors in noninsulin-dependent diabetes mellitus. Am J Cardiol 1997;79:134–9. DOI 10.1016/S0002-9149(96)00699-6.
Weiner DA, Ryan TJ, Parsons L, Fisher LD, Chaitman BR, Sheffield LT, Tristani FE. Significance of silent myocardial ischemia during exercise testing in patients with diabetes mellitus: a report from the Coronary Artery Surgery Study (CASS) registry. Am J Cardiol 1991;68:729–34.
Wackers FJT, Young LH, Inzucchi SE, Chyun DA, Davey JA. Detection of ischemia in asymptomatic diabetics: preliminary results of the DIAD study. J Am Coll Cardiol 2003;41:409a.
Rose G, Blackburn H, Gillum RF, Prineas RJ. Cardiovascular survey methods. 2nd edn. Geneva: WHO; 1982.
Imaging guidelines for nuclear cardiology procedures, part 2. American Society of Nuclear Cardiology. J Nucl Cardiol 1999;6:G47–84.
Berman DS, Kiat H, Friedman JD, Wang FP, van Train K, Matzer L, et al. Separate acquisition rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion single-photon emission computed tomography: a clinical validation study. J Am Coll Cardiol 1993;22:1455–64.
Hachamovitch R, Berman DS, Shaw LJ, Kiat H, Cohen I, Cabico JA, et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation 1998;97:535–43.
Janand-Delenne B, Savin B, Habib G, Bory M, Vague P, Lassmann-Vague V. Silent myocardial ischemia in patients with diabetes: who to screen. Diabetes Care 1999;22:1396–400.
Vanzetto G, Halimi S, Hammoud T, Fagret D, Benhamou PY, Cordonnier D, et al. Prediction of cardiovascular events in clinically selected high-risk NIDDM patients. Prognostic value of exercise stress test and thallium-201 single-photon emission computed tomography. Diabetes Care 1999;22:19–26.
Inoguchi T, Yamashita T, Umeda F, Mihara H, Nakagaki O, Takada K, et al. High incidence of silent myocardial ischemia in elderly patients with non insulin-dependent diabetes mellitus. Diabetes Res Clin Pract 2000;47:37–44. DOI 10.1016/S0168-8227(99)00102-3.
De Lorenzo A, Lima RSL, Siqueira-Filho AG, Pantoja MR. Prevalence and prognostic value of perfusion defects detected by stress technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography in asymptomatic patients with diabetes mellitus and no known coronary artery disease. Am J Cardiol 2002;90:827–32. DOI 10.1016/S0002-9149(02)02702-9.
Wackers F, Young L, Inzucchi S, Chyun D, Davey J. The prevalence of silent myocardial ischemia in asymptomatic patients with type 2 diabetes meltitus: results of the DIAD study. Diabetes 2003;52:A56.
Wackers FTJ, Young LH, Chyun DA, Davey JA, Inzucchi SE. Predictors of silent myocardial ischemia in patients with type 2 diabetes mellitus: results from the DIAD study. Diabetologia 2003;46:A23–4.
McCulloch DK, Campbell IW, Wu FC, Prescott RJ, Clarke BF. The prevalence of diabetic impotence. Diabetologia 1980;18:279–83.
Zaret B, Beller GA. Nuclear cardiology—state of the art and future directions. 2nd edn. St. Louis: Mosby; 1999.
Pancholy SB, Schalet B, Kuhlmeier V, Cave V, Heo J, Iskandrian AS. Prognostic significance of silent ischemia. J Nucl Cardiol 1994;1:434–40.
Valensi P, Sachs RN, Lormeau B, Taupin JM, Ouzan J, Blasco A, et al. Silent myocardial ischaemia and left ventricle hypertrophy in diabetic patients. Diabetes Metab 1997;23:409–16.
Cosson E, Guimfack M, Paries J, Paycha F, Attali JR, Valensi P. Are silent coronary stenoses predictable in diabetic patients and predictive of cardiovascular events? Diabetes Metab 2003;29:470–6.
Zeiher AM, Krause T, Schachinger V, Minners J, Moser E. Impaired endothelium-dependent vasodilation of coronary resistance vessels is associated with exercise-induced myocardial ischemia. Circulation 1995;91:2345–52.
Schindler TH, Nitzsche E, Magosaki N, Brink I, Mix M, Olschewski M, et al. Regional myocardial perfusion defects during exercise, as assessed by three dimensional integration of morphology and function, in relation to abnormal endothelium dependent vasoreactivity of the coronary microcirculation. Heart 2003;89:517–26.
Hasdai D, Gibbons RJ, Holmes Jr DR, Higano ST, Lerman A. Coronary endothelial dysfunction in humans is associated with myocardial perfusion defects. Circulation 1997;96:3390–5.
Blumenthal RS, Becker DM, Yanek LR, Aversano TR, Moy TF, Kral BG, Becker LC. Detecting occult coronary disease in a high-risk asymptomatic population. Circulation 2003;107:702–7. DOI 10.1161/01.CIR.0000048127.93169.88.
Verna E, Ceriani L, Giovanella L, Binaghi G, Garancini S. “False-positive” myocardial perfusion scintigraphy findings in patients with angiographically normal coronary arteries: insights from intravascular sonography studies. J Nucl Med 2000;41:1935–40.
Nitenberg A, Ledoux S, Valensi P, Sachs R, Attali JR, Antony I. Impairment of coronary microvascular dilation in response to cold pressor-induced sympathetic stimulation in type 2 diabetic patients with abnormal stress thallium imaging. Diabetes 2001;50:1180–5.
Nitenberg A, Valensi P, Sachs R, Cosson E, Attali JR, Antony I. Prognostic value of epicardial coronary artery constriction to the cold pressor test in type 2 diabetic patients with angiographically normal coronary arteries and no other major coronary risk factors. Diabetes Care 2004;27:208–15.
Schachinger V, Britten MB, Zeiher AM. Prognostic impact of coronary vasodilator dysfunction on adverse long-term outcome of coronary heart disease. Circulation 2000;101:1899–906.
Halcox JPJ, Schenke WH, Zalos G, Mincemoyer R, Prasad A, Waclawiw MA, et al. Prognostic value of coronary vascular endothelial dysfunction. Circulation 2002;106:653–8. DOI 10.1161/01.CIR.0000025404.78001.D8.
Acknowledgements
We would like to acknowledge the help of our nuclear medicine technician staff and of our physicians in performing the clinical studies (Drs. A. Boubaker, M.-F. Bézy, N. Besseghir, V. Vaclavik, M. Piller, G. Storto, G. Barghouth, J.-P. Willi, C. Müller, C. Antonescu, F. Bonvin and M. Zwimpfer). We are also greatly indebted to Prof. H.R. Schelbert, Drs. T.H. Schindler and X.-L. Zhang (Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, USA) for critical comments and suggestions.
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Prior, J.O., Monbaron, D., Koehli, M. et al. 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 32, 60–69 (2005). https://doi.org/10.1007/s00259-004-1591-0
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DOI: https://doi.org/10.1007/s00259-004-1591-0