Prevalence of Unrecognized Silent Myocardial Ischemia and Its Association With Atherosclerotic Risk Factors in Noninsulin-Dependent Diabetes Mellitus

doi:10.1016/S0002-9149(96)00699-6

The American Journal of Cardiology

Volume 79, Issue 2, 15 January 1997, Pages 134-139

https://doi.org/10.1016/S0002-9149(96)00699-6 Get rights and content

Abstract

To determine the prevalence of unrecognized silent myocardial ischemia, 925 noninsulin-dependent diabetic outpatients (333 women and 592 men), aged 40 to 65 years, asymptomatic, free from known coronary artery disease (CAD), advanced diabetic retinopathy, and nephropathy, severe hypertension, and poor prognosis disease, underwent exercise electrocardiogram (ECG), followed, if abnormal, by an exercise thallium scintigraphy. The exercise ECG tests were abnormal in 112 patients (12.1%, 31 women, 81 men), of whom 59 (6.4%, 12 women, 47 men) had perfusion defects at thallium scintigraphy. Adopting the more restrictive criteria (positive response to both tests) the prevalence of silent CAD resulted in 6.4%. Multivariate analysis showed that in the whole population and in the men, the associated independent risk factors were age, total cholesterol, proteinuria, and ST-T abnormalities at ECG at rest. This last factor had the highest odds ratio (9.27, confidence interval [CI] 4.44 to 19.38) and was the only one identified also in women. The relevance of ST-T abnormalities at ECG at rest as a predicting factor for silent CAD outlines the importance of a periodical ECG at rest in noninsulin-dependent diabetic patients and suggests an indication of performance of further investigations in presence of these abnormalities.

Section snippets

Cases and Protocol

The present study involved the Diabetology and Cardiology Centers of seven hospitals in the Milan area. The protocol consisted in performing a maximal exercise electrocardiogram (ECG) followed by exercise thallium scintigraphy in the presence of a positive or equivocal result.[13] Each Diabetology Center consecutively enrolled 160 noninsulin-dependent diabetic outpatients of both sexes, aged 40 to 65 years, asymptomatic and with no previously known CAD. Exclusion criteria were: insulin therapy,

Electrocardiogram at Rest

The findings were normal in 837 patients. There was a fascicular anterior block in 3 patients, a right focal block in 2, signs of left ventricular hypertrophy in 24, and ST-T abnormalities in 59.

Exercise Electrocardiogram

The test was normal in 813 subjects (87.9%) and abnormal in 112 (12.1%, 81 men and 31 women). The test was judged positive in 70 patients (7.6%, 55 men and 15 women) for ST-segment depression. The test was judged equivocal in 42 patients (4.5%, 26 men and 16 women) for ST-segment depression in 27 and

Discussion

The reported prevalence data of unrecognized silent CAD in diabetic subjects are quite different, ranging from 9% to 48%.4, 5, 6, 7, 8, 9, 10, 11, 12 This variability could be due to the different patients' selection criteria and diagnostic approaches. In most studies patients are grouped either with insulin-dependent and noninsulin-dependent diabetes,4, 5, 6, 7, 8, 9 or with noninsulin-dependent diabetes and impaired glucose tolerance.10, 11 Some studies included subjects with a specific

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Cited by (207)

Microvascular dysfunction, vasospastic angina, and silent ischaemia
2021, Medicine (Spain)
Casi dos tercios de los pacientes con angina no presentan lesiones obstructivas en la angiografía coronaria. Es importante descartar en estos pacientes la presencia de disfunción microvascular o angina vasoespástica. La disfunción microvascular coronaria engloba las alteraciones producidas en los vasos menores de 500 μm. Se pierde la capacidad de producir una correcta vasodilatación y no se puede aumentar el flujo coronario en situaciones de estrés, provocando isquemia. En los últimos años, se han desarrollado métodos de diagnóstico invasivo durante el cateterismo, el principal es la reserva de flujo coronario. El tratamiento está dirigido a mejorar la función endotelial. Se recomienda el uso de IECA/ARA II, bloqueadores beta-adrenérgicos (BBA) y estatinas.
La angina vasoespástica se produce por una vasoconstricción de las arterias epicárdicas o de las arterias de la microcirculación (disfunción microvascular). Se debe descartar en pacientes con angina de reposo de predominio nocturno. Si se sospecha, está indicada una prueba de provocación durante el cateterismo con acetilcolina, ergonovina o sustancia P. Responden a calcioantagonistas y nitratos. También se recomiendan IECA y estatinas. Los BBA están contraindicados.
Se denomina isquemia silente a la presencia de isquemia sin síntomas. Es más frecuente en pacientes diabéticos. El retraso diagnóstico que supone condiciona el pronóstico.
Almost two thirds of patients with angina show no obstructive lesions on coronary angiography. It is important to rule out microvascular dysfunction or vasospastic angina in these patients. Microvascular dysfunction encompasses abnormalities in vessels smaller than 500 μm. The capacity for correct vasodilation is lost and coronary flow cannot be increased in situations of stress causing ischaemia. In recent years, invasive diagnostic methods during catheterisation have been developed, the main method being coronary flow reserve. The aim of treatment is to improve endothelial function. ACE inhibitors/ARBs, beta-adrenergic-blocking drugs (BABs), and statins are recommended.
Vasospastic angina is caused by vasoconstriction of the epicardial arteries or the arteries of microcirculation (microvascular dysfunction). It should be ruled out in patients with predominantly nocturnal rest angina. If suspected, provocation testing is indicated during catheterisation with acetylcholine, ergonovine or substance P. It responds to calcium antagonists and nitrates. ACE inhibitors and statins are also recommenced. BABs are contraindicated.
Asymptomatic ischaemia is termed silent ischaemia. It is more frequent in diabetic patients. Diagnostic delay will determine prognosis.
Risk stratification and screening for coronary artery disease in asymptomatic patients with diabetes mellitus: Position paper of the French Society of Cardiology and the French-speaking Society of Diabetology
2021, Diabetes and Metabolism
Risk stratification and screening for coronary artery disease in asymptomatic patients with diabetes mellitus: Position paper of the French Society of Cardiology and the French-speaking Society of Diabetology
2021, Archives of Cardiovascular Diseases
Time to reperfusion in high-risk patients with myocardial infarction undergoing primary percutaneous coronary intervention
2019, Revista Portuguesa de Cardiologia
Citation Excerpt :
Unlike other studies,1,21,23,26,42 our analysis showed no differences in the patient delay of diabetic patients. It is known that diabetic patients frequently have altered perception of pain in MI, explained by diabetic neuropathy,43 and symptoms associated with diabetes, such as sudoresis and dizziness in hypoglycemic episodes, may confuse or mask the symptoms of MI.44,45 Nevertheless, a study with a large patient population showed that symptom characteristics (typical vs. atypical) do not explain the longer patient delay in diabetic patients reported in previous studies.26
Timely reperfusion with primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction (STEMI) improves patient outcomes. In recent years, the Stent for Life (SFL) initiative in Portugal developed an action plan to improve timely access to PPCI. This study aims to evaluate performance indicators in high-risk populations (elderly, female, and diabetic patients).
Data on 1340 patients with suspected STEMI who were admitted to 18 Portuguese interventional cardiology centers were collected during a one-month period every year from 2011 to 2016. The risk of longer patient and system delay in elderly, female, and diabetic patients was assessed by logistic regression analysis.
Patient and system delays were longer in elderly patients (incremental median 32 and 40 min; p=0.001 and p<0.001, respectively). Median system delay was also longer in women (incremental median 25 min; p<0.001). Consequently, times to revascularization were longer in elderly patients (incremental median 92 min; p<0.001) and women (incremental median 67 min; p<0.001). There was no significant difference in reperfusion delay in diabetic patients.
After adjustment for gender and diabetes, elderly age was an independent predictor of patient delay longer than the median (OR 1.64; 95% CI 1.22-2.20; p=0.001) and system delay >90 min (OR 2.95; 95% CI 1.84-4.72; p<0.001).
Elderly patients showed longer patient and system delays, regardless of gender and presence of diabetes. These data suggest that the elderly subgroup should be the target of a new action by the SFL initiative.
Nos últimos anos, a Iniciativa Stent for Life (SFL) em Portugal desenvolveu um plano de ação de forma a aumentar o acesso atempado à angioplastia primária (ICPP). Este trabalho pretende avaliar os indicadores de desempenho no enfarte agudo do miocárdio com supradesnivelamento de ST (EAMCSST), em populações de alto risco: idosos, mulheres e diabéticos.
Dados de 1340 doentes com suspeita de EAMCSST, admitidos em 18 centros nacionais de cardiologia de intervenção, foram recolhidos durante um mês, em anos consecutivos (2011-2016). O risco de atraso do doente e do sistema em idosos, mulheres e diabéticos foi avaliado por análise de regressão logística.
Os atrasos do doente e do sistema foram superiores nos idosos (mediana incremental de 32 e 40 min, p = 0,001 e p < 0,001, respetivamente). A mediana do atraso do sistema também foi superior nas mulheres (mediana incremental de 25 min, p < 0,001). Consequentemente, houve tempos mais longos até à revascularização nos idosos (mediana incremental de 92 min; p < 0,001) e mulheres (mediana incremental de 67 min; p < 0,001). Não houve diferença significativa no atraso de reperfusão nos diabéticos.
Após ajuste para género e diabetes, os idosos foram o preditor independente de «atraso do doente maior que a mediana» (OR 1,64; IC95% 1,22-2,20; p = 0,001) e «atraso do sistema > 90 min» (OR 2,95; IC95% 1,84-4,72; p < 0,001).
Os idosos apresentaram maior atraso do doente e do sistema, independentemente do género e da presença de diabetes mellitus. Esses dados sugerem que o subgrupo dos idosos deve ser alvo de uma nova ação da Iniciativa SFL.
Assessment of asymptomatic ischemic heart disease using stress myocardial perfusion imaging in patients with type 2 diabetes mellitus
2018, Indian Heart Journal
Coronary artery disease (CAD) is the leading cause of death in patients with type 2 diabetes mellitus (T2DM) and may be asymptomatic.
The objective of this study was to assess the prevalence of asymptomatic myocardial ischemia in patients with T2DM using stress myocardial perfusion imaging.
We evaluated 97 consecutive patients with T2DM without clinical evidence of CAD presenting to Cardiology and Endocrinology clinics using Tc-99m MIBI gated single-photon emission–computed tomography (SPECT) myocardial perfusion imaging for the presence of asymptomatic CAD.
Abnormal myocardial perfusion was observed in 10 patients (10.3%). Of these, one half of patients had reversible myocardial perfusion defects suggestive of inducible myocardial ischemia. The other half had fixed perfusion defects suggestive of previous silent myocardial infarctions. Small and moderate reversible perfusion defects were observed in 3 and 2 patients, respectively. The fixed perfusion defects observed in 5 patients were medium sized. The presence of asymptomatic ischemia was significantly associated with age and smoking but not with other traditional cardiac risk factors.
Ten percent of patients with T2DM with no clinical evidence of CAD were found to have evidence of asymptomatic ischemia or infarction.
Screening for the Presence of Cardiovascular Disease
2018, Canadian Journal of Diabetes

View all citing articles on Scopus

¹: See Appendix for a list of investigators and their affiliations.

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Prevalence of Unrecognized Silent Myocardial Ischemia and Its Association With Atherosclerotic Risk Factors in Noninsulin-Dependent Diabetes Mellitus

Abstract

Section snippets

Cases and Protocol

Electrocardiogram at Rest

Exercise Electrocardiogram

Discussion

Am J Cardiol

Am J Cardiol

Am J Med

Am J Cardiol

Am J Cardiol

Am J Cardiol

Diabetes and atherosclerosis: an epidemiologic view

Diabetes Metab Rev

Diabetes mellitus and macrovascular complications. An epidemiological perspective

Diabetes Care

Silent myocardial ischemia: classification, prevalence and prognosis

Am J Med

Asymptomatic myocardial ischemia in diabetes and its relationship to diabetic neuropathy: an exercise electrocardiography study in middle-aged diabetic men

Diabetes Care

The exercise test in diabetic patients as studied by radio-electrocardiography

Circulation

Prevalence of asymptomatic myocardial ischaemia in diabetic subjects

Br Med J

Exercise testing with myocardial scintigraphy in asymptomatic diabetic males

Circulation

Resting electrocardiographic abnormalities suggestive of asymptomatic ischemic heart disease associated with non-insulin-dependent diabetes mellitus in a defined population

Circulation