Editorial Diabetes and Screening for Coronary Heart Disease: Where Should We Focus our Efforts? Diabetes y cribado de enfermedad coronaria: ? do ´ nde centramos el esfuerzo? Jesu ´s Marı ´a de la Hera, a, * Jose ´ Manuel Garcı ´a-Ruiz, b and Elı ´as Delgado c a Unidad de Imagen Cardiaca, A ´ rea del Corazo ´n, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain b Unidad de Cuidados Cardiolo ´gicos Agudos, A ´ rea del Corazo ´n, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain c Servicio de Endocrinologı´a, Hospital Universitario Central de Asturias, Facultad de Medicina, Universidad de Oviedo, Oviedo, Asturias, Spain Article history: Available online 29 July 2015 Diabetes mellitus (DM) and coronary heart disease (CHD) are interrelated diseases that can behave as 2 sides of the same coin: on one side, patients with CHD have a high prevalence of known and unknown DM, up to 45%, 1 and on the other side, cardiovascular disease causes 65% to 70% of deaths in diabetic patients. 2 The classic assertion that DM is a coronary risk equivalent is based on a follow- up study of the 2 populations by Haffner et al 3 and the increased cardiovascular mortality of diabetic patients and is largely the reason why the American Diabetes Association proposed active screening for CHD in the diabetic population until 2007. Its current guidelines no longer endorse any imaging modality for this purpose. 4 The latest joint guidelines of the European Society of Cardiology and the European Association for the Study of Diabetes (2013) implicitly propose that cardiologists and diabetologists mutually screen for DM and CHD in their patients (Figure 1). Nonetheless, the explicit level of their CHD screening recommenda- tion in DM is low (class IIb, level of evidence C). 5 The simple truth is that there is little agreement among scientific societies in their CHD screening recommendations. Of 14 guidelines analyzed by Ferket et al, 6 8 advised against screening, 6 recommended imaging techniques in the moderate- to high-risk population according to the Framingham scale, and only 2 included cost-effectiveness analyses. In addition, the level of quality (Appraisal of Guidelines, Research, and Evaluation [AGREE] scale) of the guideline development was highly variable. 6 Thus, there are currently no solid studies identifying at-risk patients and the recommended diagnostic techniques, leading to heteroge- neous recommendations among the different scientific societies. The requirements to be met by screening programs for diseases are summarized in the Table. Next, these sections are expanded upon in the area of CHD and DM. PREVALENCE AND PROGNOSTIC IMPACT OF ASYMPTOMATIC CORONARY HEART DISEASE IN DIABETIC PATIENTS The reported prevalence of asymptomatic CHD varies widely (5%-58%), depending on the type of study (randomized, observational, prospective, or retrospective), the level of risk of the diabetic population studied, and the diagnostic technique used. Initial studies reported a prevalence of abnormal coronary perfusion of 58% in asymptomatic diabetic patients studied with single-photon emission computed tomography (SPECT) imaging, and 18% of the overall population had high-risk criteria (> 10% ischemic myocardium), showing an annual mortality of 5.9%. 7 The main criticism of this work is its retrospective nature, with clear selection biases in the sample. From the same era, but with a prospective and randomized design, is the DIAD study, 8 which randomized diabetic patients without evidence of cardiovascular disease to conventional medical treatment alone or to medical treatment and screening for CHD with SPECT. The prevalence of abnormal SPECT was 22%, but only 4 of the 561 patients studied had high-risk ischemia. Coronary computed tomography studies provided the most recent data, indicating that only 30% of the diabetic population studied was completely free of CHD; on the other hand, the prevalence of 3-vessel obstructive CHD was only 5% to 6%. 9,10 Regarding prognosis, populations are divided according to their annual mortality (< 1%, low risk; 1%–3%, moderate risk, and > 3%, high risk). The 5.9% annual mortality in the subgroup with high- grade ischemia with SPECT in the retrospective work of Rajagopalan et al 7 has already been mentioned. However, the DIAD study again showed a lower rate of events in the overall population (0.6% annual rate of death and infarction) that reached an annual rate of 1.5% in the high-risk subgroup (according to the UKPDS scale) with moderate to severe ischemia. 11 The recently published FACTOR-64 trial randomized 900 diabetic patients to computed tomography and optimal medical therapy or optimal medical therapy alone, finding a 1% annual mortality rate in the entire population. 9 The authors attributed the low incidence of events to the excellent medical management of their series (baseline systolic blood pressure, 130  11 mmHg; low-density lipoprotein cholesterol, 87  33 mg/dL), which was much better than that of the older series. 7,8 The current prevalence of CHD and cardiovascular events in the diabetic population should lead us to reconsider if DM is now a coronary risk equivalent. Death from ischemic heart disease has decreased due to both better CHD management and primary prevention. 12 Thus, our priority should be to offer our Rev Esp Cardiol. 2015;68(10):830–833 * Corresponding author: Unidad de Imagen Cardiaca, A ´ rea del Corazo ´ n, Hospital Universitario Central de Asturias, Avda. de Roma s/n, 33011 Oviedo, Asturias, Spain. E-mail address: jesusdelahera@gmail.com (J.M. de la Hera). http://dx.doi.org/10.1016/j.rec.2015.05.014 1885-5857/ß 2015 Sociedad Espan ˜ ola de Cardiologı ´a. Published by Elsevier Espan ˜a, S.L.U. All rights reserved. Document downloaded from https://www.revespcardiol.org/?ref=2033048847, day 25/10/2022. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Document downloaded from https://www.revespcardiol.org/?ref=2033048847, day 25/10/2022. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.