Effects of a myocardial ischaemia-guided therapeutic program on survival and incidence of coronary events in asymptomatic patients with diabetes: the ARCADIA study

• Published in: Diabetes & metabolism Vol. 33; no. 6; pp. 459 - 465
• Main Authors: Vanzetto, G, Boizel, R, Halimi, S, Ormezzano, O, Belle, L, Fagret, D, Machecourt, J
• Format: Journal Article
• Language: English
• Published: Paris Elsevier Masson SAS 01.12.2007; Masson
• Subjects: Aged; Aged, 80 and over; Biological and medical sciences; Cardiology. Vascular system; Coronaropathie; Coronary artery disease; Coronary Disease - epidemiology; Coronary heart disease; Diabetes mellitus; Diabetes Mellitus, Type 1 - drug therapy; Diabetes Mellitus, Type 2 - drug therapy; Diabetes. Impaired glucose tolerance; Diabetic Angiopathies - epidemiology; Diabète; Electrocardiography; Endocrine pancreas. Apud cells (diseases); Endocrinology & Metabolism; Endocrinopathies; Etiopathogenesis. Screening. Investigations. Target tissue resistance; Female; France - epidemiology; Heart; Humans; Hypoglycemic Agents - therapeutic use; Incidence; Internal Medicine; Ischémie myocardique; Male; Medical sciences; Middle Aged; Myocardial ischemia; Myocardial Ischemia - therapy; Myocardial perfusion imaging; Patient Selection; Revascularisation; Revascularization; Risk Factors; Scintigraphie myocardique; Survivors; France; major adverse cardiac event; Myocardial perfusion imaging; Ischémie myocardique; Diabetes mellitus; exercise stress test; CAD; EST; MPI; Diabète; Scintigraphie myocardique; ECG; Myocardial ischemia; Revascularisation; Coronary artery disease; electrocardiogram; MACE; Coronaropathie; Revascularization; Endocrinopathy; Human; Prognosis; Cardiovascular disease; Asymptomatic; Scintigraphy; Myocardial disease; Coronary heart disease; Survival; Incidence; Vascular disease
• ISSN: 1262-3636; 1878-1780
• DOI: 10.1016/j.diabet.2007.06.006

Abstract Aim To assess the prognostic impact of a therapeutic program based on bioclinical risk-stratification and myocardial-perfusion-imaging (MPI) data on survival and the occurrence of coronary events (CE = death + myocardial infarction) in asymptomatic patients with diabetes. Method Five hundred twenty one consecutive asymptomatic diabetic outpatients were prospectively enrolled and clinically classified as being at either low or high cardiac risk. All high-risk patients ( n = 245, age 61 ± 9 years) underwent MPI and an intensive multifactorial medical therapeutic program, including anti-ischaemic agents in cases of moderate ischemia; a coronary angiography was performed in all high-risk patients with severe ischaemia ( n = 38), followed by immediate revascularization if necessary ( n = 21). Low-risk patients ( n = 276, age 57 ± 9 years) underwent medical management of their risk factors. Results At the 19-month (median) follow-up (range, 12–36 months), both high- and low-risk patients showed similarly low CE rates (2.3% and 1.5% per year, respectively; age- and gender-adjusted log-rank P = NS). None of the patients who underwent myocardial revascularization experienced any CEs, and none of the low-risk patients died during follow-up. The negative predictive value of first-line bioclinical stratification was 0.98 for the occurrence of CEs, and 0.95 when low-risk patients were combined with high-risk patients who had normal MPI findings. Conclusions Bioclinical first-line stratification allows identification of diabetic patients who have a good medium-term cardiac prognosis. The CE rate is similar in selected high-risk asymptomatic patients with diabetes using an intensive MPI-guided program that combines medical therapy, coronary angiography in the 16% of cases with severe ischemia and, if appropriate, revascularization.