Skip to main content
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care
  • Subscribe
  • Log in
  • My Cart
  • Follow ada on Twitter
  • RSS
  • Visit ada on Facebook
Clinical Diabetes

Advanced Search

Main menu

  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • Quality Improvement Sucess Stories
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
  • Advertising
  • Reprints/Reuse
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Submit Cover Art
    • Instructions for Authors
    • ADA Journal Policies
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care

User menu

  • Subscribe
  • Log in
  • My Cart

Search

  • Advanced search
Clinical Diabetes
  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • Quality Improvement Sucess Stories
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
  • Advertising
  • Reprints/Reuse
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Submit Cover Art
    • Instructions for Authors
    • ADA Journal Policies
Departments

Screening for Asymptomatic Coronary Artery Disease With Myocardial Perfusion Imaging Does Not Reduce Cardiovascular Events in Middle-Aged and Older Patients With Diabetes

  1. Michael Pignone, MD, MPH
    Clinical Diabetes 2009 Jul; 27(3): 113-114. https://doi.org/10.2337/diaclin.27.3.113
    PreviousNext
    • Article
    • Info & Metrics
    • PDF
    Loading

    STUDY

    Young LH, Wackers FJ, Chyun DA, Davey JA, Barrett EJ, Taillefer R, Heller GV, Iskandrian AE, Wittlin SD, Filipchuk N, Ratner RE, Inzucchi SE; DIAD Investigators: Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study: a randomized, controlled trial. JAMA 301:1547-1555, 2009

    SUMMARY

    Design. A multicenter, randomized trial.

    Subjects. The study included 1,123 adults ages 50-75 years with type 2 diabetes and no history of symptomatic coronary heart disease (CHD). Mean age was 60 years, 23% were of self-reported non-white race, and just over half were men. The mean LDL cholesterol level was 114 mg/dl and mean systolic blood pressure was 132 mmHg, and 10% of subjects were current smokers. Just fewer than half of participants were taking lipid-lowering medication, a similar proportion were taking aspirin, and just more than 20% were using insulin.

    Methods. Eligible participants were randomly assigned to either receive screening with adenosine-stress radionuclide myocardial perfusion imaging (MPI) or receive no screening. The stress MPI tests were reviewed locally by nuclear cardiologists, and their results were provided to the participants and their physicians. MPI tests were also evaluated separately by an independent expert panel, with quantification of the size of the perfusion abnormality and identification of nonperfusion abnormalities. Further testing and treatment decisions were made by the participants' physicians and were not dictated by trial protocol. The primary endpoint was the incidence of nonfatal myocardial infarction (MI) and cardiac death. Analysis was on an intention-to-treat basis.

    Results. During a mean of 4.8 years of follow-up, the cumulative incidence of nonfatal MI and cardiac death was 2.7% in the screening group and 3.0% in the control group (hazard ratio [HR] 0.88, 95% CI 0.44-1.88) Among those in the screened group, incidence was lower for those with no (n = 400) or small (n = 50) perfusion defects compared with the 33 participants with moderate or large defects (2 vs. 12.1%, HR 6.3, 95% CI 1.9-20.1). Utilization of effective treatments such as statins and antihypertensive medications increased during the trial but did not differ between screening and no-screening groups. Similarly, use of cardiac catheterization or revascularization, although initially higher in the screened group, did not differ between groups during the entire study.

    Conclusions. Screening with MPI did not reduce CHD events in this population of patients with diabetes, but the relatively low-risk nature of the trial participants limits definitive conclusions about its effects.

    COMMENTARY

    CHD is an important cause of morbidity and mortality in adults, particularly those with diabetes. CHD events, including angina, MI, and sudden cardiac death, can be predicted with multivariate risk equations that incorporate age, sex, blood pressure, lipid levels, smoking status, and the presence of diabetes or glucose levels. These risk predictions can be used to guide decisions about preventive therapies.

    The most common risk prediction equations for U.S. populations are derived from the Framingham Heart Study and have been shown to have relatively good accuracy overall, although their performance in patients with diabetes is somewhat limited by their use of a crude measure (presence or absence of diabetes) and the relatively small number of people with diabetes included in the cohort from which these risk equations were derived.1,2

    Because middle-aged and older patients with diabetes generally have high risks of CHD events, some experts have suggested that all adults with diabetes be considered at high risk and treated accordingly.3 Some have suggested that more aggressive screening is warranted in diabetes to better detect high-risk patients and treat them even more aggressively.4 Potential additional screening tests include computed tomography scanning for coronary calcium, exercise or pharmacological stress imaging, and carotid ultrasound examination. Such tests have been shown to be associated with higher event rates, even after controlling for standard risk factors, but their effect on treatment decision making and actual CHD outcomes has not been well studied, and more recent recommendations have called for more research.5

    In that context, the Detection of Ischemia in Asymptomatic Diabetics (DIAD) trial was designed to examine the effects of routine screening with MPI for adults with diabetes ages 50-75 years and no history of symptomatic coronary disease. The design of the trial was well suited to address whether routine screening itself would change outcomes. There was little loss to follow-up, and a high proportion of participants in the screening arm received the MPI test. During the course of the study, a relatively large proportion (30%) of control group members received a similar type of test, but this should not be considered a flaw because it reflects the correct comparison (routine screening vs. testing as clinically warranted).

    The observed CHD event rate among participants was quite a bit lower than anticipated in the design of the trial (0.6% per year, compared with an expected rate of 1-2% per year). As a result, the main estimate of effect in the trial had a very wide confidence interval (0.44-1.88) that did not allow for a conclusion with confidence that the intervention produced net benefit, net harm, or no net effect.

    The 12% of participants with moderate or large perfusion defects had higher event rates (2.4% per year) compared with participants with small or no defects, who had low event rates (0.4% per year). Whether the stratification of risk achieved with stress MPI produces sufficient benefit to justify its costs depends on how the information is used for treatment decision making and whether the differences in treatment produce more benefit than harm.

    Several factors make it difficult to demonstrate benefit from screening. First, the threshold for prescribing many effective therapies, including statins and antihypertensive medication, is being pushed lower as better information emerges about treatment efficacy and safety and costs decrease with availability of generic versions of key medications.6 In that sense, further stratification of risk will not change the decision about treatment because it is warranted even in quite low-risk (0.5% per year) patients. Second, it is unclear whether further testing with cardiac catheterization and revascularization produces any benefit among those found to have abnormal screening tests. Although this question has not been definitively answered, available evidence suggests that large benefits are unlikely. Finally, the results of DIAD suggest that, in practice, providers and patients do not make substantially different decisions about treatment in the face of MPI results compared to when no such screening tests are available.

    Given these factors and the high cost of MPI screening, it is unlikely that routine use of such tests represents a good allocation of resources and effort for CHD prevention. Working to improve treatment and adherence to proven effective therapies for patients at moderate or high risk based on standard risk assessment should remain the primary focus for CHD prevention efforts at this time.

    Footnotes

    • Michael Pignone, MD, MPH, is an associate professor of medicine at the University of North Carolina Department of Medicine in Chapel Hill and an associate editor of Clinical Diabetes.

    • American Diabetes Association(R) Inc., 2009

    REFERENCES

    1. ↵
      1. Wilson PW,
      2. D'Agostino RB,
      3. Levy D,
      4. Belanger AM,
      5. Silbershatz H,
      6. Kannel WB
      : Prediction of coronary heart disease using risk factor categories. Circulation 97:1837-1847, 1998
      OpenUrlAbstract/FREE Full Text
    2. ↵
      1. Coleman RL,
      2. Stevens RJ,
      3. Retnakaran R,
      4. Holman RR
      : Framingham, SCORE, and DECODE risk equations do not provide reliable cardiovascular risk estimates in type 2 diabetes. Diabetes Care 30:1292-1293, 2007
      OpenUrlFREE Full Text
    3. ↵
      1. Haffner SM,
      2. Lehto S,
      3. Rönnemaa T,
      4. Pyörälä K,
      5. Laakso M
      : Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 339:229-234, 1998
      OpenUrlCrossRefPubMedWeb of Science
    4. ↵
      1. American Diabetes Association
      : Consensus development conference on the diagnosis of coronary heart disease in people with diabetes: 10-11 February 1998, Miami, Florida. Diabetes Care 21:1551-1559, 1998
      OpenUrlFREE Full Text
    5. ↵
      1. Bax JJ,
      2. Young LH,
      3. Frye RL,
      4. Bonow RO,
      5. Steinberg HO,
      6. Barrett EJ,
      7. American Diabetes Association
      : Screening for coronary artery disease in patients with diabetes. Diabetes Care 30:2729-2736, 2007
      OpenUrlAbstract/FREE Full Text
    6. ↵
      1. Pletcher MJ,
      2. Lazar L,
      3. Bibbins-Domingo K,
      4. Moran A,
      5. Rodondi N,
      6. Coxson P,
      7. Lightwood J,
      8. Williams L,
      9. Goldman L
      : Comparing impact and cost-effectiveness of primary prevention strategies for lipid-lowering. Ann Intern Med 150:243-254, 2009
      OpenUrlCrossRefPubMedWeb of Science
    View Abstract
    PreviousNext
    Back to top

    In this Issue

    July 2009, 27(3)
    • Table of Contents
    • Index by Author
    Sign up to receive current issue alerts
    View Selected Citations (0)
    Print
    Download PDF
    Article Alerts
    Sign In to Email Alerts with your Email Address
    Email Article

    Thank you for your interest in spreading the word about Clinical Diabetes.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    Screening for Asymptomatic Coronary Artery Disease With Myocardial Perfusion Imaging Does Not Reduce Cardiovascular Events in Middle-Aged and Older Patients With Diabetes
    (Your Name) has forwarded a page to you from Clinical Diabetes
    (Your Name) thought you would like to see this page from the Clinical Diabetes web site.
    CAPTCHA
    This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
    Citation Tools
    Screening for Asymptomatic Coronary Artery Disease With Myocardial Perfusion Imaging Does Not Reduce Cardiovascular Events in Middle-Aged and Older Patients With Diabetes
    Michael Pignone
    Clinical Diabetes Jul 2009, 27 (3) 113-114; DOI: 10.2337/diaclin.27.3.113

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
    Add to Selected Citations
    Share

    Screening for Asymptomatic Coronary Artery Disease With Myocardial Perfusion Imaging Does Not Reduce Cardiovascular Events in Middle-Aged and Older Patients With Diabetes
    Michael Pignone
    Clinical Diabetes Jul 2009, 27 (3) 113-114; DOI: 10.2337/diaclin.27.3.113
    del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
    • Tweet Widget
    • Facebook Like
    • Google Plus One

    Jump to section

    • Article
      • STUDY
      • SUMMARY
      • COMMENTARY
      • Footnotes
      • REFERENCES
    • Info & Metrics
    • PDF

    Related Articles

    Cited By...

    More in this TOC Section

    Departments

    • Community Primary Care Diabetes Pathway
    • Increasing Attendance at Scheduled Appointments for Group Classes at a Diabetes Education Center
    • Case Reports on Diabetes-Related Outcomes for Pregnant Women in the National Diabetes Prevention Program
    Show more Departments

    Landmark Studies

    • Television Viewing Increases Risk of Type 2 Diabetes, Cardiovascular Disease, and Mortality
    • The Effect of Fruit and Vegetable Intake on the Incidence of Diabetes
    • High-Protein and Low-Glycemic Diets Improve Weight Maintenance Among Overweight Adults
    Show more Landmark Studies

    Similar Articles

    Navigate

    • Current Issue
    • Papers in Press
    • Abridged Standards of Care
    • Archives
    • Submit
    • Subscribe
    • Email Alerts
    • RSS Feeds

    More Information

    • About the Journal
    • Instructions for Authors
    • Journal Policies
    • Reprints and Permissions
    • Advertising
    • Privacy Policy: ADA Journals
    • Copyright Notice/Public Access Policy
    • Contact Us

    Other ADA Resources

    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • Scientific Sessions Abstracts
    • Standards of Medical Care in Diabetes
    • BMJ Open - Diabetes Research & Care
    • Professional Books
    • Diabetes Forecast

     

    • DiabetesJournals.org
    • Diabetes Core Update
    • ADA's DiabetesPro
    • ADA Member Directory
    • Diabetes.org

    © 2021 by the American Diabetes Association. Clinical Diabetes Print ISSN: 0891-8929, Online ISSN: 1945-4953.