Prognostic relevance of symptoms versus objective evidence of coronary artery disease in diabetic patients*1

AIM: Little is known about the prognostic significance of silent versus symptomatic coronary artery disease (CAD) in diabetic patients. We therefore assessed the incidence of scintigraphic evidence of CAD in diabetic patients without known CAD and the impact of symptoms and scintigraphic findings on prognosis. METHODS AND RESULTS: A consecutive series of 1737 diabetic patients without known CAD underwent dual-isotope myocardial perfusion SPECT (MPS) and 1430 were followed-up for a median of 2 (1-8.5) years. Critical events were defined as myocardial infarction or cardiac death. Objective evidence of CAD was found in 39% of 826 asymptomatic diabetic patients, in 51% of 151 diabetic patients with shortness of breath (SOB), and in 44% of 760 diabetic patients with angina. During follow-up, 98 critical events occurred. Annual critical event rates were 2.2% in asymptomatic, 3.2% in angina, and 7.7% in diabetic patients with shortness of breath ( p < 0.001 versus other groups). With MPS evidence of CAD, critical event rates increased to 3.4% (asymptomatic), 5.6% (angina), and 13.2% (SOB) ( p </= 0.009 versus no evidence of CAD). Age, hypertension, shortness of breath, scarring and ischaemia were independent predictors of critical events. MPS findings added incremental information to prescan information regarding outcome prediction. CONCLUSIONS: In asymptomatic diabetic patients, the rate of objective evidence of CAD and annual critical events were similar to those found in diabetic patients with angina. The outcome was three times worse in diabetic patients with shortness of breath. MPS findings were strongly predictive of outcome and proved valuable for risk stratification.