Cardiovascular Screening for the Asymptomatic Patient with Diabetes: More Cons Than Pros

Table 2

Studies examining the role of screening for CHD on outcomes in diabetes persons and the role of revascularization procedures.

(a)

Silent CHD/ischaemia screening studies
Study name	Screening method	Patients (n)	Age (years)	Smoking (%)	Statin use (%)	Aspirin use (%)	Mean follow-up (years)	Silent CHD-ischaemia (%)	Main outcome
Faglia et al. ([116])	Exercise ECG and dipyridamole-stress echo	71	58.7 ± 8.3	46	28	9	4.4	21.4	In the screened arm, the proportion of all events () as well as the proportion of major to minor events () was significantly less
	No screening	70	61.5±8.1	55	21	12		NA
DIAD (Young et al. [117])	Stress scintigraphy	561	60.7 ± 6.7	10	37	43	4.8	22	No difference in cardiac death or nonfatal MI (HR): 0.88; 95% CI: 0.44–1.88;
	No screening	562	60.8 ± 6.4	9	41	46		NA
DYNAMIT (Lièvre et al. [118])	Bicycle exercise test or stress scintigraphy	316	64.1 ± 6.4	17	33	39	3.5	21.5	No difference in composite primary endpoint (death from all causes, nonfatal MI, nonfatal stroke, or heart failure requiring emergency intervention) between the screening and the nonscreening group (2.6% versus 2.4% annually; adjusted HR: 1.0; 95% CI: 0.59–1.71)
	No screening	315	63.7 ± 6.4	14	36	24		NA
FACTOR-64 (Muhlestein et al. [119])	Coronary CT angiogram (CCTA)	452	61.5 ± 7.9	16	76	43	4.0	69	The primary outcome event rates not significantly different between the CCTA and the control groups (6.2% versus 7.6%; hazard ratio: 0.80 [95% CI: 0.49–1.32]; )
	No screening	448	61.6 ± 8.3	15	72	40		NA
DADDY-D (Turrini et al. [120])	Exercise ECG	262	61.9 ± 4.8	40	39	29	3.6	7.6	No difference in cardiac events (HR = 0.85, 95% CI: 0.39–1.83, ) or occurrence of first HF episode (HR = 0.27, 95% CI: 0.06–1.31, )
	No screening	258	62 ± 5.1	37	44	25		NA

(b)

Outcome studies
Study name	Group randomization	Patients (n)	Age (years)	Smoking (%)	Statin use (%)	Aspirin use (%)	Mean follow-up(years)	Silent CHD-ischaemia (%)	Main Outcome
COURAGE (Boden et al. [135])	Medical therapy plus PCI with bare-metal stenting	1149	61.5 ± 10.1	23	86	96	4.6	NA (all participants had known CHD)	No difference for the primary endpoint of death from any cause and nonfatal MI (cumulative incidence approximately 19% in both groups; HR: 1.05; 95% CI: 0.87–1.27; ). No significant difference in rates of hospitalization for acute coronary syndrome (approximately 12% in both groups; HR: 1.07; 95% CI: 0.84–1.37; ). Patients in PCI group underwent significantly fewer subsequent revascularization procedures (21% versus 33%, HR: 0.60, 95% CI: 0.51–0.71)
	Medical therapy alone	1138	61.8 ± 9.7	23	89	95
BARI 2D (Mori Brooks et al. [136])	Revascularization (PCI or CABG) with intensive medical therapy (IMT)	953	62.3 ± 8.8	10.4	94.6	93.5	5	NA (all participants had known CHD)	No difference in primary endpoints of survival or freedom from major CVD events (death, MI, or stroke) between the revascularization and IMT groups (88.3% versus 87.8% and 77.2% versus 75.9%, resp.)
	IMT alone	991	62.4 ± 9.0	11.2	95.4	94.2
BARDOT (Zellweger et al. [121])	Positive MPI with SPECT (MPS)	87	65 ± 7	32	66	63	2	22	Patients with abnormal MPS randomized to medical versus invasive-medical strategies had similar hard event rates ((HR: 0.36; 95% CI: 0.07 to 1.81; ), but more ischemic or new scar findings on repeat scintigraphy (54.3% versus 15.8%; )
	Negative MPS	313	63 ± 8	18	55	50

CHD: coronary heart disease; ECG: electrocardiogram; echo: echocardiography; NA: not applicable; DIAD: Detection of Ischemia in Asymptomatic Diabetics; DYNAMIT: Do You Need to Assess Myocardial Ischemia in Type-2 diabetes; DADDY-D: Does coronary Atherosclerosis Deserve to be Diagnosed earlY in Diabetic patients; COURAGE: Clinical Outcomes Using Revascularization and Aggressive Drug Evaluation; BARI 2D: Bypass Angioplasty Revascularization Investigation 2 Diabetes; BARDOT: Basel Asymptomatic high-Risk Diabetics’ Outcome Trial.