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Cited by 809Cardiac Imaging and DiagnosticsDiabetes, Cardiovascular Risks, and LipoproteinsHealth Promotion and Cardiovascular Prevention

Cardiac Outcomes After Screening for Asymptomatic Coronary Artery Disease in Patients With Type 2 Diabetes: The DIAD Study: A Randomized Controlled Trial

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Young, Lawrence H., Wackers, Frans J. Th., Chyun, Deborah A., Davey, Janice A., Barrett, Eugene J., Taillefer, Raymond, Heller, Gary V., Iskandrian, Ami E. +5 more·2009·JAMA
DOI 10.1001/jama.2009.476PMC PMC2895332
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Abstract

CONTEXT: Coronary artery disease (CAD) is the major cause of mortality and morbidity in patients with type 2 diabetes. But the utility of screening patients with type 2 diabetes for asymptomatic CAD is controversial. OBJECTIVE: To assess whether routine screening for CAD identifies patients with type 2 diabetes as being at high cardiac risk and whether it affects their cardiac outcomes. DESIGN, SETTING, AND PATIENTS: The Detection of Ischemia in Asymptomatic Diabetics (DIAD) study is a randomized controlled trial in which 1123 participants with type 2 diabetes and no symptoms of CAD were randomly assigned to be screened with adenosine-stress radionuclide myocardial perfusion imaging (MPI) or not to be screened. Participants were recruited from diabetes clinics and practices and prospectively followed up from August 2000 to September 2007. MAIN OUTCOME MEASURE: Cardiac death or nonfatal myocardial infarction (MI). RESULTS: The cumulative cardiac event rate was 2.9% over a mean (SD) follow-up of 4.8 (0.9) years for an average of 0.6% per year. Seven nonfatal MIs and 8 cardiac deaths (2.7%) occurred among the screened group and 10 nonfatal MIs and 7 cardiac deaths (3.0%) among the not-screened group (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.44-1.88; P = .73). Of those in the screened group, 409 participants with normal results and 50 with small MPI defects had lower event rates than the 33 with moderate or large MPI defects; 0.4% per year vs 2.4% per year (HR, 6.3; 95% CI, 1.9-20.1; P = .001). Nevertheless, the positive predictive value of having moderate or large MPI defects was only 12%. The overall rate of coronary revascularization was low in both groups: 31 (5.5%) in the screened group and 44 (7.8%) in the unscreened group (HR, 0.71; 95% CI, 0.45-1.1; P = .14). During the course of study there was a significant and equivalent increase in primary medical prevention in both groups. CONCLUSION: In this contemporary study population of patients with diabetes, the cardiac event rates were low and were not significantly reduced by MPI screening for myocardial ischemia over 4.8 years. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00769275.

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  • In the DIAD trial involving 1,123 individuals with type 2 diabetes and no symptoms of CAD, screening with adenosine-stress radionuclide myocardial perfusion imaging for myocardial ischemia more than 4.8 years did not alter rates of cardiac events.

    “the DIAD trial involving 1,123 individuals with type 2 diabetes and no symptoms of CAD found that screening with adenosine-stress radionuclide myocardial perfusion imaging for myocardial ischemia more than 4.8 years did not alter rates of cardiac events”

    From Exercise and Type 2 Diabetes (2010) · cites this paper as [288]

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  • A randomized observational trial demonstrated no clinical benefit of routine screening with adenosine-stress radionuclide myocardial perfusion imaging in asymptomatic people with type 2 diabetes and normal ECGs.

    “A randomized observational trial demonstrated no clinical benefit of routine screening with adenosine-stress radionuclide myocardial perfusion imaging in asymptomatic people with type 2 diabetes and normal ECGs (210).”

    From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [210]

    The Abstract and Comment describe a randomized controlled trial and report that MPI screening did not significantly reduce cardiac events in asymptomatic patients with type 2 diabetes. The Methods excluded specified abnormal resting ECG findings, but did not require an entirely normal ECG. The claim's description of an observational trial and its unqualified 'normal ECGs' are therefore inaccurate. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • A randomized trial demonstrated no clinical benefit of routine screening with adenosine-stress radionuclide myocardial perfusion imaging in asymptomatic people with type 2 diabetes and normal ECGs.

    “A randomized trial demonstrated no clinical benefit of routine screening with adenosine-stress radionuclide myocardial perfusion imaging in asymptomatic people with type 2 diabetes and normal ECGs (199).”

    From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [199]

  • Data from a meta-analysis of five RCTs with 3299 asymptomatic patients with diabetes showed non-invasive CAD screening significantly reduced the rate of any cardiac event by 27% (RR 0.73; 95% CI, 0.55-0.97; P = 0.028), driven by a non-significant reduction in non-fatal MI (RR 0.65; P = 0.062) and hospitalization for HF (RR 0.61; P = 0.1).

    “Data from a meta-analysis of five RCTs with 3299 asymptomatic patients with diabetes showed non-invasive CAD screening significantly reduced the rate of any cardiac event by 27% (RR 0.73; 95% CI, 0.55-0.97;P = 0.028), driven by a non-significant reduction in non-fatal MI (RR 0.65; P = 0.062) and hospitalization for HF (RR 0.61; P = 0.1).”

    From 2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes. (2023) · cites this paper as [389]

  • Among asymptomatic people with type 2 diabetes and normal ECGs, although over one in five had abnormal myocardial perfusion imaging, screened and unscreened groups had similar and very low cardiac outcomes.

    “Despite abnormal myocardial perfusion imaging in more than one in fi ve patients, cardiac outcomes were essentially equal (and very low) in screened versus unscreened patients.”

    From 10. Cardiovascular Disease and Risk Management: <i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [178]

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Authors
Young, L. H., Wackers, F. J. T., Chyun, D. A., Davey, J. A., Barrett, E. J., Taillefer, R., Heller, G. V., Iskandrian, A. E., Wittlin, S. D., Filipchuk, N., Ratner, R. E., Inzucchi, S. E., & DIAD Investigators, F. T.
Affiliations
  • Yale University (US)
  • University of Alabama at Birmingham (US)
Corresponding author
Wackers, Frans J. Th.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2009-04-15
Volume
301
Issue
15
Pages
1547
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2009.476
PMC
PMC2895332
OpenAlex
W1996082994
Cited by
809
References
38
Citations by year
2026: 11 · 2025: 12 · 2024: 14 · 2023: 36 · 2022: 19 · 2021: 42 · 2020: 41 · 2019: 42 · 2018: 45 · 2017: 52 · 2016: 53 · 2015: 84 · 2014: 67 · 2013: 64 · 2012: 57
FWCI
57.18
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Center for Research Resources (M01RR000125, M01 RR-00125, 5 M01 RR00847, 6M01-RR-05096, M01RR000847, M01RR005096)
Topics
  • Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
Keywords
asymptomatic coronary artery disease, cardiac screening, myocardial infarction, cardiovascular mortality, coronary revascularization, positive predictive value, primary prevention, risk stratification, myocardial ischemia detection
MeSH terms
Adenosine, Coronary Artery Disease, Diabetes Mellitus, Type 2, Diabetic Angiopathies, Exercise Test, Female, Humans, Male, Middle Aged, Myocardial Infarction, Vasodilator Agents, Technetium Tc 99m Sestamibi, Radiopharmaceuticals, Myocardial Perfusion Imaging

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