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Cited by 791Cardiac Imaging and DiagnosticsCardiovascular Function and Risk FactorsDiabetes, Cardiovascular Risks, and Lipoproteins

Detection of Silent Myocardial Ischemia in Asymptomatic Diabetic Subjects

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Wackers, Frans J.Th., Young, Lawrence H., Inzucchi, Silvio E., Chyun, Deborah A., Davey, Janice A., Barrett, Eugene J., Taillefer, Raymond, Wittlin, Steven D. +6 more·2004·Diabetes Care
DOI 10.2337/diacare.27.8.1954
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Abstract

OBJECTIVE—To assess the prevalence and clinical predictors of silent myocardial ischemia in asymptomatic patients with type 2 diabetes and to test the effectiveness of current American Diabetes Association screening guidelines. RESEARCH DESIGN AND METHODS—In the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study, 1,123 patients with type 2 diabetes, aged 50–75 years, with no known or suspected coronary artery disease, were randomly assigned to either stress testing and 5-year clinical follow-up or to follow-up only. The prevalence of ischemia in 522 patients randomized to stress testing was assessed by adenosine technetium-99m sestamibi single-photon emission–computed tomography myocardial perfusion imaging. RESULTS—A total of 113 patients (22%) had silent ischemia, including 83 with regional myocardial perfusion abnormalities and 30 with normal perfusion but other abnormalities (i.e., adenosine-induced ST-segment depression, ventricular dilation, or rest ventricular dysfunction). Moderate or large perfusion defects were present in 33 patients. The strongest predictors for abnormal tests were abnormal Valsalva (odds ratio [OR] 5.6), male sex (2.5), and diabetes duration (5.2). Other traditional cardiac risk factors or inflammatory and prothrombotic markers were not predictive. Ischemic adenosine-induced ST-segment depression with normal perfusion (n = 21) was associated with women (OR 3.4). Selecting only patients who met American Diabetes Association guidelines would have failed to identify 41% of patients with silent ischemia. CONCLUSIONS—Silent myocardial ischemia occurs in greater than one in five asymptomatic patients with type 2 diabetes. Traditional and emerging cardiac risk factors were not associated with abnormal stress tests, although cardiac autonomic dysfunction was a strong predictor of ischemia.

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  • Studies have found that a risk factor-based approach to the initial diagnostic evaluation and subsequent follow-up for coronary artery disease fails to identify which people with type 2 diabetes will have silent ischemia on screening tests.

    “Studies have also found that a risk factor-based approach to the initial diagnostic evaluation and subsequent follow-up for coronary artery disease fails to identify which people with type 2 diabetes will have silent ischemia on screening tests (212,213).”

    From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [212]

    The Clinical implications section (p. 6) says the two-or-more-risk-factor screening recommendation did not accurately identify many patients with abnormal tests, supporting the claim about initial screening. It also says the study addressed silent ischemia only at enrollment and that five-year follow-up results were still forthcoming; it does not support the claim about subsequent follow-up. (LLM, conf=0.88)

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  • Studies have found that a risk factor-based approach to the initial diagnostic evaluation and subsequent follow-up for coronary artery disease fails to identify which people with type 2 diabetes will have silent ischemia on screening tests.

    “Studies have also found that a risk factor–based approach to the initial diagnostic evaluation and subsequent follow-up for coronary artery disease fails to identify which people with type 2 diabetes who will have silent ischemia on screening tests (201,202).”

    From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [201]

    The Clinical implications section (p. 6) says the two-or-more-risk-factor screening recommendation missed many patients with test abnormalities, supporting the claim about initial screening. It also says these data address only silent ischemia at enrollment and that follow-up evaluation was still planned; this paper does not establish the claim about subsequent follow-up. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • Using a risk factor-based approach for initial diagnostic evaluation and follow-up of coronary artery disease does not identify which patients with type 2 diabetes will show silent ischemia on screening tests.

    “Studies have found that a risk factor-based approach to the initial diagnostic evaluation and subsequent follow-up for coronary artery disease fails to identify which people with type 2 diabetes will have silent ischemia on screening tests (179,180).”

    From 10. Cardiovascular Disease and Risk Management: <i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [179]

  • Autonomic neuropathy is strongly associated with CVD in people with diabetes.

    “Autonomic neuropathy is also strongly associated with CVD in people with diabetes (130,131).”

    From Standards of Medical Care in Diabetes—2009 (2009) · cites this paper as [130]

  • A risk factor-based approach to initial diagnostic evaluation and follow-up fails to identify which patients will have silent ischemia on screening tests.

    “However, recent studies concluded that using this approach fails to identify which patients will have silent ischemia on screening tests (130,221).”

    From Standards of Medical Care in Diabetes—2009 (2009) · cites this paper as [130]

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  1. [7]7. American Heart Association: Prevention Conference VI: diabetes and cardiovascular disease. Circulation 105:2231-2239, 2002

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Authors
Wackers, F. J. T., Young, L. H., Inzucchi, S. E., Chyun, D. A., Davey, J. A., Barrett, E. J., Taillefer, R., Wittlin, S. D., Heller, G. V., Filipchuk, N., Engel, S., Ratner, R. E., Iskandrian, A. E., & for the Detection of Ischemia in Asymptomatic Diabetics (DIAD) Investigators
Affiliations
  • Yale University (US)
  • University of Virginia (US)
  • Université de Montréal (CA)
  • University of Rochester Medicine (US)
  • Hartford Hospital (US)
  • Cardiology Consultants, Calgary, Canada
  • Soundview Research Associates, Norwalk, Connecticut
  • MedStar Health Research Institute (US)
  • University of Alabama at Birmingham (US)
ORCID
Venue
Diabetes Care
Publisher
American Diabetes Association
Published
2004-08-01
Volume
27
Issue
8
Pages
1954-1961
ISSN
  • 0149-5992 (ISSN-L)
  • 1935-5548
DOI
10.2337/diacare.27.8.1954
OpenAlex
W2159222156
Cited by
791
References
41
Citations by year
2026: 5 · 2025: 12 · 2024: 6 · 2023: 13 · 2022: 15 · 2021: 20 · 2020: 23 · 2019: 28 · 2018: 30 · 2017: 34 · 2016: 34 · 2015: 35 · 2014: 46 · 2013: 51 · 2012: 42
FWCI
50.56
Type
journal article
Language
en
Update notices
correction (2005-02-01)
Open access
Locations
  • Diabetes Care (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • Yale University
  • National Center for Research Resources (5-M01-RR-00044, M01RR000125, M01 RR-00125, 5 M01 RR00847, M01RR000044, M01RR000847, 5M01 RR0596)
Topics
  • Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
Keywords
silent myocardial ischemia, type 2 diabetes, asymptomatic patients, coronary artery disease, stress testing, myocardial perfusion imaging, 99mTc-sestamibi, cardiac autonomic dysfunction, Valsalva maneuver, ST-segment depression, diabetes duration, cardiovascular risk factors, prevalence
MeSH terms
Canada, Coronary Disease, Diabetes Mellitus, Type 1, Diabetic Angiopathies, Exercise Test, Female, Humans, Male, Middle Aged, Outpatients, United States, Tomography, Emission-Computed, Single-Photon, Myocardial Ischemia, Technetium Tc 99m Sestamibi, Radiopharmaceuticals

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