Cardiovascular Risk Prediction Is Improved by Adding Asymptomatic Coronary Status to Routine Risk Assessment in Type 2 Diabetic Patients

OBJECTIVE—To evaluate if silent myocardial ischemia (SMI) and silent coronary artery dis-ease (CAD) provide significant additional value to routine cardiovascular risk assessment in type 2 diabetic patients. RESEARCHDESIGNANDMETHODS—We followed up to a first cardiovascular event 688 subjects (322 men, aged 596 8 years) out of 731 consecutive asymptomatic type 2 diabetic patients with$1 additional risk factor who had been prospectively screened between 1992 and 2006 for SMI by stress myocardial scintigraphy and for silent CAD by coronary angiography. RESULTS—SMI was found in 207 (30.1%) patients and CAD in 76 of those with SMI. Of the patients, 98 had a first cardiovascular event during a 5.46 3.5 (range: 0.1–19.2) year follow-up period. Cox regression analysis considering parameters predicting events but not SMI and CAD (“routine assessment”) showed in univariate analyses that macroproteinuria (hazard ratio [HR] 3.33 [95%CI 1.74–6.35]; P, 0.001), current multifactorial care (0.27 [0.15–0.47]; P, 0.001), and peripheral/carotid occlusive arterial disease (PCOAD; 4.33 [2.15–8.71]; P, 0.001) inde-pendently predicted cardiovascular events. When added into the model, SMI (HR 1.76 [1.00– 3.12]; P = 0.05) and CAD (2.28 [1.24–4.57]; P, 0.01) were also independently associated with events. SMI added to the prediction of an event in the following 5 years above and beyond routine assessment risk prediction (c statistic with or without SMI 0.788 [0.720–0.855] and 0.705 [0.616–0.794], respectively). CONCLUSIONS—Although screening for SMI and silent CAD should not be systematic, these complications are predictive of cardiovascular events in type 2 diabetic patients in addition to routine risk predictors, especially represented by PCOAD, macroproteinuria, and noninten-sive management. Type 2 diabetes is associated with ahigh prevalence of coronary arterydisease (CAD) and cardiovascular events (1,2). Other cardiovascular risk factors are common in this population and must be taken into account for the estimation of the cardiovascular risk, such as in the United Kingdom Prospec-tive Diabetes Study (UKPDS) risk engin