Cardiac imaging for risk stratification in diabetes

With the alarming worldwide increase in diabetes, and the associated high cardiovascular morbidity/mortality, adequate diagnostic tools are needed to detect CAD and risk stratify patients. On the one hand, functional imaging tools (nuclear techniques, echocardiography, and MRI) are available, which allow assessment of ischemia. In general, which particular technique is preferred depends on local expertise and accordingly varies among institutions. The choice for each technique may vary among institutions, and local expertise may be the best guide. On the other hand, anatomical imaging tools (computed tomography techniques) are now available, which allow assessment of atherosclerosis. Although there are less data concerning the diagnostic accuracy of functional and anatomical testing in patients with diabetes, available information suggests similar accuracies in diabetic patients compared with the general population. The advantage of anatomical testing is that both obstructive and nonobstructive (subclinical) CAD can be visualized, allowing detection of atherosclerosis at an early stage. However, information on the homodynamic consequences of the detected lesions (needed to determine further management) is not obtained. Integration of these imaging techniques therefore may provide optimal information to guide patient management. In asymptomatic patients with diabetes, studies have observed a considerably elevated prevalence of silent ischemia and atherosclerosis, suggesting the need for screening in this population. However, no prospective data are currently available, and improved outcome based on screening has not yet been demonstrated. Large, randomized, prospective trials are therefore required to determine the potential role of screening asymptomatic patients with diabetes for CAD.