In patients with diabetes and stable chest pain, computed tomographic (CT) angiography may the preferred modality to evaluate them for possible coronary artery disease, according to study results published in the Journal of the American College of Cardiology.
Diabetes is a well-known risk factor for cardiovascular disease. However, the best noninvasive screening test for coronary artery disease in this population has still not been determined. The goal of this study was to compare an anatomic approach (CT angiography) with a functional approach (exercise electrocardiogram, stress nuclear imaging, or nuclear echocardiogram) for evaluating the risk for cardiovascular outcomes in patients with and without diabetes. In addition, the researchers assessed differences in processes of care, including referral for invasive coronary angiography and preventative therapies.
The PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) study included 10,003 symptomatic stable outpatients without a history of coronary artery disease randomly assigned to initial testing with CT angiography or functional testing. The analysis included 1908 and 7058 patients with and without diabetes, respectively, with available data.
The findings indicated that compared with patients without diabetes, patients with diabetes were referred more frequently to invasive coronary angiography following functional stress testing (9.3% vs 12.6%, respectively). Patients who underwent CT angiography were more likely to be referred to invasive coronary angiography compared with patients who underwent functional stress testing.
In patients with diabetes, the risk for adverse cardiovascular events was lower in patients who had CT angiography compared with patients who had functional stress testing. The risk for cardiovascular mortality or myocardial infarction was lower in patients with diabetes who underwent CT angiography (10 of 936 patients, 1.1%) compared with functional stress testing (25 of 972 patients, 2.6%; adjusted hazard ratio, 0.38; 95% CI, 0.18-0.79; P =.01). No similar difference were evident in patients without diabetes.
The researchers acknowledged the inherent limitation of this post-hoc analysis, the small number of cardiovascular mortality/myocardial infarction cases, and no data regarding risk factor control. In addition, the diagnosis of diabetes was based on patient- and site-identified history of the disease or the use of antihyperglycemic medications, but was not formally established by glycated hemoglobin or fasting glucose levels.
“In evaluating stable patients with diabetes who have symptoms suggestive of [coronary artery disease], physicians should consider these benefits of using [CT angiography] as the initial diagnostic strategy,” concluded the researchers.
Please refer to reference for a complete list of authors’ disclosures.
Sharma A, Coles A, Sekaran NK, et al. Stress testing versus CT angiography in patients with diabetes and suspected coronary artery disease. J Am Coll Cardiol. 2019;73(8):893-902.