title: Detecting silent coronary stenoses and stratifying cardiac risk in patients with diabetes: ECG stress test or exercise myocardial scintigraphy?
abstract: OBJECTIVE
  To determine whether performing a myocardial scintigraphy immediately after a maximal electrocardiogram (ECG) stress test is effective in detecting silent coronary stenoses and predicting cardiovascular events.
  
  
  METHODS
  Asymptomatic patients (n = 262) aged 57.6 +/- 8.8 years, with diabetes for 12.0 years (5-39) [median (range)] and no history of a cardiac event, underwent a maximal ECG stress test followed by a myocardial scintigraphy. The patients with an abnormal ECG stress test or abnormal imaging underwent a coronary angiography. Cardiac events were assessed in 250 (95.4%) patients followed for 37.8 months (3-101).
  
  
  RESULTS
  The ECG stress test was abnormal in 54 patients. Among them, 18 had coronary stenoses and seven had a cardiac event. Despite a normal ECG stress test, the myocardial scintigraphy was abnormal in 42 additional patients, including 16 patients with coronary stenoses. Four of these 42 patients experienced a cardiac event. Follow-up showed a poor prognosis in subjects who were abnormal on the two tests. Univariate predictors of the 15 cardiac events were the ECG stress test [odds ratio (OR) 3.9, 95% confidence interval (CI) 1.3, 11.4, P = 0.008], myocardial scintigraphy (OR 3.8, 95% CI 1.3, 11.0, P = 0.009), coronary stenoses (OR 26.6, 95% CI 7.6, 90.7, P < 0.001), and peripheral or carotid occlusive arterial disease (OR 9.5, 95% CI 2.1, 42.5, P < 0.001).
  
  
  CONCLUSIONS
  In the asymptomatic patients with diabetes, combining a myocardial scintigraphy with a maximal ECG stress test is effective in detecting more patients with coronary stenoses and predicting cardiovascular events. However, the ECG stress test has a good negative predictive value for cardiac events (97%), is cheaper, and should therefore be proposed first.
authors.affiliation: Department of Endocrinology-Diabetology-Nutrition, AP-HP, Paris-Nord University, Jean Verdier Hospital, Bondy, France. emmanuel.cosson@jvr.ap-hop-paris.fr
authors.forename: E
authors.initials: E
authors.lastname: Cosson
authors.forename: F
authors.initials: F
authors.lastname: Paycha
authors.forename: J
authors.initials: J
authors.lastname: Paries
authors.forename: S
authors.initials: S
authors.lastname: Cattan
authors.forename: A
authors.initials: A
authors.lastname: Ramadan
authors.forename: D
authors.initials: D
authors.lastname: Meddah
authors.forename: J-R
authors.initials: JR
authors.lastname: Attali
authors.forename: P
authors.initials: P
authors.lastname: Valensi
mesh_terms: D002318:Cardiovascular Diseases / Q000175:diagnosis; D015331:Cohort Studies; D017023:Coronary Angiography; D023921:Coronary Stenosis / Q000175:diagnosis* / Q000000981:diagnostic imaging; D003925:Diabetic Angiopathies / Q000175:diagnosis* / Q000000981:diagnostic imaging; D004562:Electrocardiography; D005080:Exercise Test; D005260:Female; D006321:Heart / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000175:diagnosis / Q000000981:diagnostic imaging; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D011877:Radionuclide Imaging; D012307:Risk Factors