Diabetes Metab J.  2011 Feb;35(1):34-40. 10.4093/dmj.2011.35.1.34.

Exercise Treadmill Test in Detecting Asymptomatic Coronary Artery Disease in Type 2 Diabetes Mellitus

• Kim MK
• Baek KH
• Song KH
• Kwon HS
• Lee JM
• Kang MI
• Yoon KH
• Cha BY
• Son HY
• Lee KW

• KMID: 2281490
• DOI: http://doi.org/10.4093/dmj.2011.35.1.34

Abstract

BACKGROUND
The present study was designed to develop criteria for screening patients with type 2 diabetes mellitus (T2DM) for asymptomatic coronary artery disease (CAD).
METHODS
A total of 213 patients with T2DM without typical angina or chest pain were studied between 2002 and 2007. We also evaluated 53 patients with T2DM who had reported chest discomfort using an exercise treadmill test (ETT).
RESULTS
Thirty-one of the 213 asymptomatic patients had positive ETT results. We performed coronary angiography on 23 of the 31 patients with a positive ETT and found that 11 of them had significant coronary stenosis. The main differences between the patients with significant stenosis and those with a negative ETT were age (63.1+/-9.4 vs. 53.7+/-10.1 years, P=0.008) and duration of diabetes (16.0+/-7.5 vs. 5.5+/-5.7 years, P<0.001). The positive predictive value (PPV) of the ETT was calculated to be 47.8%. The PPV of the ETT increased to 87.5% in elderly patients (> or =60 years) with a long duration of diabetes (> or =10 years). The latter value is similar to that of patients with T2DM who presented with chest discomfort or exertional dyspnea. The PPV of the ETT in symptomatic patients was 76.9%.
CONCLUSION
In the interest of cost-effectiveness, screening for asymptomatic CAD could be limited to elderly patients with a duration of diabetes > or =10 years.

Keyword

Diabetes mellitus; Duration of diabetes; Exercise treadmill test; Silent myocardial ischemia

MeSH Terms

Aged
Chest Pain
Constriction, Pathologic
Coronary Angiography
Coronary Artery Disease
Coronary Stenosis
Coronary Vessels
Diabetes Mellitus
Diabetes Mellitus, Type 2
Dyspnea
Exercise Test
Humans
Mass Screening
Thorax

Figure

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  Fig. 1 Flowchart of patients who underwent the exercise treadmill test.

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  Fig. 2 Positive predictive values (PPV) of an exercise treadmill test (ETT) for coronary artery stenosis. DM, diabetes mellitus.

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  Fig. 3 Flowchart of elderly patients (≥60 years) with a long duration of diabetes (≥10 years). CAG, coronary angiography.

Reference

1. Alexander CM, Landsman PB, Teutsch SM. Diabetes mellitus, impaired fasting glucose, atherosclerotic risk factors, and prevalence of coronary heart disease. Am J Cardiol. 2000. 86:897–902.

2. Choi EK, Koo BK, Kim HS, Cho YM, Kang HJ, Cho YS, Chung WY, Chae IH, Choi DJ, Oh BH, Park YB, Choi YS. Prognostic significance of asymptomatic coronary artery disease in patients with diabetes and need for early revascularization therapy. Diabet Med. 2007. 24:1003–1011.

3. Goraya TY, Leibson CL, Palumbo PJ, Weston SA, Killian JM, Pfeifer EA, Jacobsen SJ, Frye RL, Roger VL. Coronary atherosclerosis in diabetes mellitus: a population-based autopsy study. J Am Coll Cardiol. 2002. 40:946–953.

4. Rutter MK, Nesto RW. The changing costs and benefits of screening for asymptomatic coronary heart disease in patients with diabetes. Nat Clin Pract Endocrinol Metab. 2007. 3:26–35.

5. Bax JJ, Young LH, Frye RL, Bonow RO, Steinberg HO, Barrett EJ. ADA. Screening for coronary artery disease in patients with diabetes. Diabetes Care. 2007. 30:2729–2736.

6. Bacci S, Villella M, Villella A, Langialonga T, Grilli M, Rauseo A, Mastroianno S, De Cosmo S, Fanelli R, Trischitta V. Screening for silent myocardial ischaemia in type 2 diabetic patients with additional atherogenic risk factors: applicability and accuracy of the exercise stress test. Eur J Endocrinol. 2002. 147:649–654.

7. Araz M, Celen Z, Akdemir I, Okan V. Frequency of silent myocardial ischemia in type 2 diabetic patients and the relation with poor glycemic control. Acta Diabetol. 2004. 41:38–43.

8. 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. 22:1396–1400.

9. Buse JB, Ginsberg HN, Bakris GL, Clark NG, Costa F, Eckel R, Fonseca V, Gerstein HC, Grundy S, Nesto RW, Pignone MP, Plutzky J, Porte D, Redberg R, Stitzel KF, Stone NJ. American Heart Association. American Diabetes Association. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation. 2007. 115:114–126.

10. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2003. 26:Suppl 1. S5–S20.

11. Gibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF, Froelicher VF, Mark DB, Marwick TH, McCallister BD, Thompson PD Jr, Winters WL, Yanowitz FG, Ritchie JL, Gibbons RJ, Cheitlin MD, Eagle KA, Gardner TJ, Garson A Jr, Lewis RP, O'Rourke RA, Ryan TJ. ACC/AHA Guidelines for Exercise Testing. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol. 1997. 30:260–311.

12. Penfornis A, Zimmermann C, Boumal D, Sabbah A, Meneveau N, Gaultier-Bourgeois S, Bassand JP, Bernard Y. Use of dobutamine stress echocardiography in detecting silent myocardial ischaemia in asymptomatic diabetic patients: a comparison with thallium scintigraphy and exercise testing. Diabet Med. 2001. 18:900–905.

13. Valensi P, Sachs RN, Lormeau B, Taupin JM, Ouzan J, Blasco A, Nitenberg A, Metz D, Paries J, Talvard O, Leutenegger M, Attali JR. Silent myocardial ischaemia and left ventricle hypertrophy in diabetic patients. Diabetes Metab. 1997. 23:409–416.

14. Djaberi R, Beishuizen ED, Pereira AM, Rabelink TJ, Smit JW, Tamsma JT, Huisman MV, Jukema JW. Non-invasive cardiac imaging techniques and vascular tools for the assessment of cardiovascular disease in type 2 diabetes mellitus. Diabetologia. 2008. 51:1581–1593.

15. Xanthos T, Ekmektzoglou KA, Papadimitriou L. Reviewing myocardial silent ischemia: specific patient subgroups. Int J Cardiol. 2008. 124:139–148.

16. Smith-Bindman R, Lipson J, Marcus R, Kim KP, Mahesh M, Gould R, Berrington de Gonzalez A, Miglioretti DL. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009. 169:2078–2086.

17. 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. 1998. 21:1551–1559.

18. Scognamiglio R, Negut C, Ramondo A, Tiengo A, Avogaro A. Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus. J Am Coll Cardiol. 2006. 47:65–71.

19. American Diabetes Association. Standards of medical care in diabetes--2009. Diabetes Care. 2009. 32:Suppl 1. S13–S61.

20. Yoo WS, Kim HJ, Kim D, Lee MY, Chung HK. Early detection of asymptomatic coronary artery disease in patients with type 2 diabetes mellitus. Korean J Intern Med. 2009. 24:183–189.