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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;11\\\/8\\\/29\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;11\\\/8\\\/29\u0022}],\u0022ac\u0022:{\u0022spmdc;11\\\/8\\\/29\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;11\\\/8\\\/29\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cp id=\u0022p-1\u0022\u003EDiabetes is a potent risk factor for cardiovascular disease (CVD), and cardiovascular (CV)-related mortality is higher among individuals with diabetes. Yet, recommendations for CVD screening among asymptomatic people with diabetes are not straightforward, said Wendy Post, MD, MS, FACC, Johns Hopkins University, Baltimore, Maryland, USA.\u003C\/p\u003E\u003Cp id=\u0022p-2\u0022\u003EThe purpose of screening is to identify higher-risk patients who, once identified, can be treated to reduce their risk. \u201cBut is this true for asymptomatic people with diabetes?\u201d asked Dr. Post.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EEvidence suggests that patients who are at higher CVD risk can be identified with currently available assessment tools. Coronary artery calcium (CAC) has been found to be a \u201cvery potent predictor of risk\u201d in both diabetic and nondiabetic individuals, said Dr. Post. In the MESA study, CAC predicted CVD across nondiabetic subjects in four racial\/ethnic groups, and a score of greater than 300 was associated with a nearly 10-fold increase in future events (HR=9.67) [Detrano R et al. \u003Cem\u003ENEJM\u003C\/em\u003E 2008]. In a London study, CAC was strongly associated with CV events in asymptomatic participants with type 2 diabetes [Dhakshinamurthy VA et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2006]. These studies also demonstrated that the CAC score predicted events more accurately than other traditional risk scores (such as the Framingham risk score).\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EHbA1C is also a potent predictor of risk, according to a meta-analysis of studies in diabetes. Dr. Post noted that the pooled relative risk was 1.18 (CI, 1.10 to 1.26) per 1% point increase in HbA1C [Selvin E et al. \u003Cem\u003EAnn Intern Med\u003C\/em\u003E 2004].\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EThe Detection of Silent Myocardial Ischemia in Asymptomatic Diabetic Subjects (DIAD) study has provided perhaps the most important information with which to address the question of screening in asymptomatic diabetic patients. In DIAD, 1123 asymptomatic patients with type 2 diabetes were randomly assigned to screening with adenosine stress radionuclide myocardial perfusion imaging (MPI) or to no screening, and therapy was determined by the treating physicians [Young LH et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2009]. MPI identified moderate or large defects in 33 subjects, and the event rate for this group was significantly higher than for patients with normal images (2.4% vs 0.4%; HR=6.3; p=0.001). However, there was no difference between the screened and unscreened groups in terms of myocardial infarction or cardiac death, the primary endpoint of the study, over 4.8 years of follow-up.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EIn asking why the risk of events is not decreased when diabetic, asymptomatic patients who are at increased risk are identified, Dr. Post noted, \u201cOnce we identify people with ischemia, there is no evidence that revascularization will help in patients treated with optimal medical therapy.\u201d The results of the COURAGE trial confirm this fact, as percutaneous coronary intervention with optimal medical therapy (OMT) did not improve outcomes over OMT alone, even among the 766 diabetic patients who were symptomatic [Boden WE et al. \u003Cem\u003ENEJM\u003C\/em\u003E 2007]. Similar results were found in BARI-2D, in which there was no incremental benefit of early revascularization plus OMT compared with OMT alone in terms of survival among 2287 patients with type 2 diabetes and significant CVD [BARI-2D Study Group. \u003Cem\u003ENEJM\u003C\/em\u003E 2009]; however, the early CABG group demonstrated reduced nonfatal MI over the OMT group. Revascularization can be considered in patients with persistent ischemic symptoms while on medical therapy or those with extensive ischemia.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EThe current guidelines for CVD screening among asymptomatic adults with diabetes provide somewhat conflicting recommendations. In its Standards of Medical Care in Diabetes\u20142011, the American Diabetes Association (ADA) noted that routine screening for CVD is not recommended, \u201cas it does not improve outcomes as long as CVD risk factors are treated\u201d [ADA. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2011]. However, the 2010 guidelines published by the American College of Cardiology Foundation\/American Heart Association (ACCF\/AHA) provide somewhat different recommendations, noting that measurement of CAC is \u201creasonable\u201d and that HbA1C and stress MPI \u201cmay be considered\u201d for assessing CV risk in asymptomatic adults with diabetes [Greenland P et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2010]. Dr. Post recommended that clinicians follow the AHA\/ACC guidelines for preventing CVD in diabetic patients [Buse JB et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2007]. She also described an \u201cABC approach\u201d to CVD prevention that she applies to all patients\u2014diabetic and nondiabetic, with or without symptoms (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E)\u2014in order to treat the underlying atherosclerotic process to prevent acute coronary syndromes.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/12549\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/12549\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12549\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003EABC Approach to Prevention of CV Risk.\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzn1jp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzn1jp\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}