Association of Silent Myocardial Infarction With Major Cardiovascular Events in Diabetes: The ACCORD Trial

The epidemic of diabetes continues to grow, with recent prevalence estimates of 12% among U.S. adults. Though type 2 diabetes is associated with a two- to fourfold heightened risk of cardiovascular disease, this risk is heterogeneously distributed (1). Thus, markers of cardiovascular risk beyond traditional risk factors are needed. Prior efforts to incorporate novel blood biomarkers in risk prediction have found only modest additive value in risk discrimination, despite significant economic cost (2,3). The routine 12-lead electrocardiogram (ECG) may represent a cost-effective measure to refine atherosclerotic cardiovascular disease (ASCVD) risk. Silent myocardial infarction (SMI) is more common among those with diabetes due to impaired nociception. The risk of ASCVD among those with prior SMI and diabetes has not been adequately studied. We used patient-level data from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study and the ACCORDION follow-up study to assess the additive utility of SMI for discrimination of risk. For this analysis, eligible participants were free of prevalent cardiovascular disease (defined as history of myocardial infarction, stroke, coronary revascularization, carotid or peripheral revascularization, or positive stress test) at study enrollment and had adequate baseline ECG data. SMI was defined as the presence of a …