Diabetes and the associated incidence of subclinical atherosclerosis and coronary artery disease: Implications for management

Background We sought to examine the prevalence, sensitivity, and specificity of coronary calcium (CC), a marker of atherosclerosis, in a population of symptomatic and asymptomatic diabetic persons. Methods We used electron beam tomography (EBT) to quantitate CC in 168 symptomatic (chest pain or anginal equivalent) persons with diabetes who underwent coronary angiography and then compared this with a cohort of 155 asymptomatic persons with diabetes. Results In the 168 symptomatic diabetic persons, 124 (74%) had obstructive coronary artery disease (CAD) by angiography. Receiver-operator characteristic curve analysis was used to maximize sensitivity and specificity for obstructive CAD (>50% stenosis), which established a CC score of 102 as optimal. With use of this cut point, EBT has a sensitivity of 77% and a specificity of 77% for detecting obstructive CAD. Of the 155 asymptomatic diabetic persons, 72% had CC and 48% had a CC score >102. The presumed prevalence of obstructive disease (on the basis of EBT scores and prevalence of CC) among asymptomatic diabetic persons is quite high (as high as symptomatic persons without diabetes). Analyzing the 323 diabetic patients demonstrated no significant age difference in CC scores between women and men. Conclusions This study confirms that higher CC scores should be used in diabetic patients to improve the specificity of CC to determine obstructive disease. EBT can allow a noninvasive diagnosis of CAD before clinical presentation, allowing for more therapy for those in which CC is detected. These results suggest that asymptomatic diabetic persons have the same atherogenic burden of those patients with CAD without diabetes. The high prevalence of CC in asymptomatic persons with diabetes supports the need for aggressive management of diabetes and associated risk factors. (Am Heart J 2001;141:637-44.)