Endothelial Dysfunction in Diabetic Patients with Abnormal Myocardial Perfusion in the Absence of Epicardial Obstructive Coronary Artery Disease

UNLABELLED: In patients with diabetes mellitus, myocardial perfusion defects are often observed in the absence of obstructive epicardial coronary artery disease (CAD), thereby presenting a diagnostic problem. We hypothesized that these perfusion abnormalities may be explained by endothelial dysfunction or occult coronary atherosclerosis. METHODS: Prospectively, 130 asymptomatic patients with diabetes mellitus underwent cardiovascular screening by coronary artery calcium (CAC) scoring, multislice CT coronary angiography, and myocardial perfusion imaging by SPECT. Multislice CT images were evaluated for the presence of obstructive epicardial CAD (>or=50% luminal narrowing). To quantify abnormal myocardial perfusion on SPECT images, we determined the summed stress score for each patient. The presence of abnormal myocardial perfusion was defined as a summed stress score of 3 or more. In addition, flow-mediated dilatation of the brachial artery, a marker of endothelial function, was determined using ultrasonography. RESULTS: In 35 patients (27%), obstructive epicardial CAD was observed on multislice CT, and these patients were excluded from further analysis. In the remaining 95 patients, abnormal myocardial perfusion was observed in 30 (32%) of patients. Flow-mediated dilatation was significantly lower in patients with abnormal myocardial perfusion (3.6% +/- 2.4%) than in those with normal myocardial perfusion (6.4% +/- 2.6%) (P < 0.001). Importantly, flow-mediated dilatation remained a significant predictor of the extent of abnormal myocardial perfusion after correction for cardiovascular risk factors and CAC score (P < 0.001). In contrast, no association was observed between nonobstructive plaque burden as reflected by CAC scores and extent of abnormal myocardial perfusion. CONCLUSION: In patients with diabetes mellitus, myocardial perfusion abnormalities in the absence of obstructive epicardial CAD are associated with endothelial dysfunction.