Similar CVD Risks in Diabetics With and Without Angina Symptoms

February 12, 2013

QUEBEC CITY — Patients with diabetes and stable coronary artery disease with and without angina or other symptoms have a similar risk of cardiovascular disease events and death, a new analysis suggests [1]. According to investigators, these diabetic patients with stable disease should be managed in the same way regardless of their symptom status.


"When we look at patients with symptoms, it has raised the question as to whether the symptoms have an impact on the prognosis," said lead investigator Dr Gilles Dagenais (Quebec Heart and Lung University Institute, Quebec City). "When we look at the literature, there are not a lot of data, but our hypothesis was that patients who were asymptomatic would have the same risk as patients who had angina or angina equivalents."

Published in the February 19, 2013 issue of the Journal of the American College of Cardiology, the study in fact showed that patients without angina or angina equivalents, such as dyspnea, fatigue, or sweating on exertion, had an equivalent risk of death and cardiovascular events as patients with angina or other symptoms.

Speaking with heartwire , Dagenais said these asymptomatic patients should be managed just as any patient with diabetes and stable coronary disease would be managed, meaning treatment with diet and exercise, as well as aggressive treatment of their cardiovascular risk factors. An asymptomatic patient who has a good performance on an exercise stress test should be treated like a patient with angina. If the patient has a poor performance on the treadmill, "then you have to be aggressive and send the patient for a coronary angiogram and possibly coronary revascularization."

The new study is a post hoc analysis of 2364 patients participating in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) study, so all the usual caveats apply from such an analysis, added Dagenais.

High Risk for Subsequent Disease in These Patients

In total, 1434 patients with angina, 506 with angina equivalents, and 424 patients without symptoms were included in the study. At five years, the cumulative mortality rate was 12% in patients with angina, 14% in patients with angina equivalents, and 10% in patients without symptoms. The cumulative rate of cardiovascular-disease events was 24% in patients with angina, 24% in patients with angina equivalents, and 21% in patients without symptoms. After adjustment for multiple variables, there was no difference between the asymptomatic and symptomatic patients in terms of all-cause mortality and the composite end point of cardiovascular disease death, nonfatal MI, and nonfatal stroke.

To heartwire , Dagenais said that patients with type 2 diabetes and coronary artery disease are at a high risk for subsequent cardiovascular disease. In an editorial accompanying the study [2], Dr Peter Stone (Brigham and Women's Hospital, Boston, MA) asks how to best incorporate the new BARI 2D findings into clinical care, wondering whether all patients with diabetes should be screened to determine if coronary artery disease and ischemia are present, because prognosis appears not to be related to angina symptoms but ischemic risk. Stone notes that prospective studies to date investigating such a strategy have not been conclusive.

"For now, we should certainly optimize risk-factor management for all patients with diabetes, and we will need more prospective cost-effectiveness studies to determine an optimal risk-stratification strategy for patients with diabetes at risk for coronary artery disease," writes Stone. "Given the epidemic of diabetes that is upon us, as well as the exorbitant healthcare expenditures that we currently make, we will need to be diligent in carefully assessing the risk, benefit, and cost of widespread screening." If a high-risk patient is identified, even without symptoms, it is appropriate to proceed to more detailed risk assessment as well as to consider medical vs coronary-revascularization therapy, added Stone.