Original Data

The Association of Silent Coronary Artery Disease and Metabolic Syndrome in Chinese with Type 2 Diabetes Mellitus

Jack C.-R. Tsai¹, Dao-Ming Chang², Fu-Mei Chung², Jung-Chou Wu², Shyi-Jang Shin³, Yau-Jiunn Lee¹

Abstract

OBJECTIVES: Cardiovascular diseases account for approximately 75% of the deaths that occur in patients with diabetes. Because the clinical signs of coronary artery disease (CAD) in diabetic patients are hard to detect and routine screening is costly, it would be of great benefit to try to either prevent CAD from occurring or to detect it early and provide optimal care. Therefore, we analyzed the risk factors that might predict CAD in type 2 diabetes mellitus (T2DM) patients with no classical cardiac ischemic symptoms. METHODS: Using a resting 12-lead ECG, exercise treadmill test, or thallium myocardial scintigraphy with exercise testing and dipyridamole injection, we screened diabetic patients already enrolled in a disease management program for possible CAD. We used diagnostic coronary angiography to confirm its presence. The definition and criteria of metabolic syndrome we used were modified from those outlined by the WHO classification and criteria of NCEP-ATP III. RESULTS: A total of 850 T2DM patients without clinical and electrocardiographic evidence of CAD were studied. Three hundred and sixty-eight asymptomatic patients with normal resting ECG were examined by exercise ECG test or thallium scintigraphy examination. Sixty patients considered to have a strong positive test or significant thallium myocardial ischemia received a diagnostic coronary angiography. Fifty-one were found to have significant coronary artery stenosis; 9 showed no significant ischemic lesion. While gender, patients' age, known diabetes duration, serum uric acid level, smoking status, and the presence of WHO-metabolic syndrome defined hypertension and nephropathy were associated with silent CAD, logistic regression analysis found that the only predictor of silent CAD was the presence of nephropathy. The components of NCEP-ATP III-metabolic syndrome were not found to be associated with silent CAD. CONCLUSIONS: A considerable proportion of T2DM patients have silent CAD. A diabetic patient with incipient or overt nephropathy should be examined for the presence of CAD. The definition of metabolic syndrome may be modified for early detection of CAD in patients with T2DM.

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Adherence to Guidelines and its Effects on Hospitalizations with Complications of Type 2 Diabetes

Frank A. Sloan^1,2, M. Angelyn Bethel³, Paul P. Lee⁴, Derek S. Brown², Mark N. Feinglos³

Abstract

OBJECTIVES: To study the discrepancy between actual and recommended rates of use among several measures of screening for complications of diabetes in a national longitudinal sample, the correlations among measures of adherence, and whether or not higher rates of adherence reduce hospitalizations for complications of diabetes. The key study hypothesis was that lack of adherence to professional recommendations for diabetes care leads to adverse health outcomes for elderly persons. METHODS: Administrative claims and survey data for 1994-­1999 on a nationally representative sample of Medicare beneficiaries age 65+. Principal components analysis and instrumental variables probit regression methods were used. RESULTS: Most Medicare beneficiaries diagnosed with type 2 diabetes had at least one physician visit per year, but rates of screening (eye examinations and HbA1c, lipid, microalbumin and urine tests) fell far short of recommendations. Correlations among use rates for various types of screening were positive but far less than one, suggesting that failure to screen reflects a complex set of underlying factors. Increased rates of adherence were observed for HbA1c and lipid testing over the observation period. Higher use was associated with lower rates of hospitalization for complications of diabetes (vascular (p=0.007), renal (p=0.002), and other complication (p=0.005)). CONCLUSIONS: Adherence to guidelines was associated with significantly reduced rates of hospitalization. Continued analysis of the trends in clinical practice is needed to demonstrate the effectiveness of standardized guidelines for the care of patients with diabetes.

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