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Detection of Silent Myocardial Ischemia in Asymptomatic Diabetic Subjects
Open accessAbstract
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 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]
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In the citing paper
“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]
Experimental — accuracy not yet measuredIn the citing paper
“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: Standards of Care in Diabetes—2023 (2023) · cites this paper as [179]
In the citing paper
“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]
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“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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Metadata
- 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)
- 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
- 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
- bronze
- doi.org
- 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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