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Cardiac Outcomes After Screening for Asymptomatic Coronary Artery Disease in Patients With Type 2 DiabetesThe DIAD Study: A Randomized Controlled Trial
Lawrence H. Young, MD;
Frans J. Th. Wackers, MD, PhD;
Deborah A. Chyun, MSN, PhD;
Janice A. Davey, MSN;
Eugene J. Barrett, MD;
Raymond Taillefer, MD;
Gary V. Heller, MD, PhD;
Ami E. Iskandrian, MD;
Steven D. Wittlin, MD;
Neil Filipchuk, MD;
Robert E. Ratner, MD;
Silvio E. Inzucchi, MD; for the DIAD Investigators
JAMA. 2009;301(15):1547-1555.
Context Coronary artery disease (CAD) is the major cause of mortality and morbidity in patients with type 2 diabetes. But the utility of screening patients with type 2 diabetes for asymptomatic CAD is controversial.
Objective To assess whether routine screening for CAD identifies patients with type 2 diabetes as being at high cardiac risk and whether it affects their cardiac outcomes.
Design, Setting, and Patients The Detection of Ischemia in Asymptomatic Diabetics (DIAD) study is a randomized controlled trial in which 1123 participants with type 2 diabetes and no symptoms of CAD were randomly assigned to be screened with adenosine-stress radionuclide myocardial perfusion imaging (MPI) or not to be screened. Participants were recruited from diabetes clinics and practices and prospectively followed up from August 2000 to September 2007.
Main Outcome Measure Cardiac death or nonfatal myocardial infarction (MI).
Results The cumulative cardiac event rate was 2.9% over a mean (SD) follow-up of 4.8 (0.9) years for an average of 0.6% per year. Seven nonfatal MIs and 8 cardiac deaths (2.7%) occurred among the screened group and 10 nonfatal MIs and 7 cardiac deaths (3.0%) among the not-screened group (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.44-1.88; P = .73). Of those in the screened group, 409 participants with normal results and 50 with small MPI defects had lower event rates than the 33 with moderate or large MPI defects; 0.4% per year vs 2.4% per year (HR, 6.3; 95% CI, 1.9-20.1; P = .001). Nevertheless, the positive predictive value of having moderate or large MPI defects was only 12%. The overall rate of coronary revascularization was low in both groups: 31 (5.5%) in the screened group and 44 (7.8%) in the unscreened group (HR, 0.71; 95% CI, 0.45-1.1; P = .14). During the course of study there was a significant and equivalent increase in primary medical prevention in both groups.
Conclusion In this contemporary study population of patients with diabetes, the cardiac event rates were low and were not significantly reduced by MPI screening for myocardial ischemia over 4.8 years.
Trial Registration clinicaltrials.gov Identifier: NCT00769275
Author Affiliations: Department of Internal Medicine, Section of Cardiovascular Medicine (Drs Young and Wackers and Ms Davey) and Section of Endocrinology (Dr Inzucchi), Yale University School of Medicine, New Haven, Connecticut; College of Nursing at the College of Dentistry, New York University, New York (Dr Chyun); Department of Endocrinology, University of Virginia, Charlottesville (Dr Barrett); Médecine Nucléaire, University of Montreal, Montreal, Quebec, Canada (Dr Taillefer); Department of Cardiology, Hartford Hospital, Hartford, Connecticut (Dr Heller); Department of Cardiology, University of Alabama, Birmingham (Dr Iskandrian); Department of Endocrinology, University of Rochester, Rochester, New York, (Dr Wittlin); Cardiology Consultants, Calgary, Alberta, Canada (Dr Filipchuk); and MedStar Research Institute, Washington, DC (Dr Ratner).
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