Prognostic value of calcium score and coronary flow velocity reserve in asymptomatic diabetic patients.
BACKGROUND
The risk stratification of patients with diabetes mellitus (DM) is a major objective for the clinicians, and it can be achieved by coronary flow velocity reserve (CFVR) or with coronary artery calcium score (CS). CS evaluates underlying coronary atherosclerotic plaque burden and CFVR estimates both presence of coronary artery stenosis and microvascular function. Consequently, CFVR may provide unique risk information beyond the extent of coronary atherosclerosis.


OBJECTIVE
Our aim is to assess joint prognostic value of CFVR and CS in asymptomatic DM patients.


METHODS
We prospectively included 200 asymptomatic patients (45,5 % male, mean age 57,35 ± 11,25), out of which, there were 101 asymptomatic patients with DM and 99 asymptomatic patients without DM, but with one or more conventionally risk factors for coronary artery disease. We analyzed clinical, biochemical, metabolic, inflammatory parameters, CS by Agatston method, transthoracic Doppler echocardiography CFVR of left anterior descending artery and echocardiographic parameters.


RESULTS
Total CS and CS LAD were significantly higher, while mean CFVR was lower in diabetics compared to the nondiabetics. During 1 year follow-up, 24 patients experienced cardio-vascular events (one cardiovascular death, two strokes, three myocardial infarctions, nine new onsets of unstable angina and nine myocardial revascularizations): 19 patients with DM and five non DM patients, (p = 0,003). Overall event free survival was significantly higher in non DM group, compared to the DM group (94,9 % vs. 81,2 %, p = 0,002 respectively), while the patients with CS ≥200 and CFVR <2 had the worst outcome during 1 year follow up in the whole study population as well as in the DM group. At multivariable analysis CFVR on LAD (HR 12.918, 95 % CI 3.865-43.177, p < 0.001) and total CS (HR 13.393, 95 % CI 1.675-107.119, p = 0.014) were independent prognostic predictors of adverse events in DM group of patients.


CONCLUSIONS
Both CS and CFVR provide independent and complementary prognostic information in asymptomatic DM patients. When two parameters are analyzed together, the risk stratification ability improves, even when DM patients are analyzed together with non DM patients. As a result, DM patients with CS ≥200 and CFVR <2 had the worst outcome. Consequently, the use of two tests identified subset of patients who can derive the most benefit from the intensive prevention measures.
Clinic for Cardiology, Clinical Center of Serbia, Visegradska 26, 11000, Belgrade, Serbia. miodrag.dikic@gmail.com.
Miodrag
M
Dikic
Clinic for Cardiology, Clinical Center of Serbia, Visegradska 26, 11000, Belgrade, Serbia. misa.tesic@gmail.com.
Milorad
M
Tesic
Medical School, University of Belgrade, Belgrade, Serbia. dr.markovic@gmail.com.|Clinic for Radiology, Clinical Center of Serbia, Belgrade, Serbia. dr.markovic@gmail.com.
Zeljko
Z
Markovic
Clinic for Cardiology, Clinical Center of Serbia, Visegradska 26, 11000, Belgrade, Serbia. voja2011@yahoo.com.|Medical School, University of Belgrade, Belgrade, Serbia. voja2011@yahoo.com.
Vojislav
V
Giga
Clinic for Cardiology, Clinical Center of Serbia, Visegradska 26, 11000, Belgrade, Serbia. skali.ana7@gmail.com.|Medical School, University of Belgrade, Belgrade, Serbia. skali.ana7@gmail.com.
Ana
A
Djordjevic-Dikic
Clinic for Cardiology, Clinical Center of Serbia, Visegradska 26, 11000, Belgrade, Serbia. jelena.stepanovic@kcs.ac.rs.|Medical School, University of Belgrade, Belgrade, Serbia. jelena.stepanovic@kcs.ac.rs.
Jelena
J
Stepanovic
Clinic for Cardiology, Clinical Center of Serbia, Visegradska 26, 11000, Belgrade, Serbia. branko.beleslin@gmail.com.|Medical School, University of Belgrade, Belgrade, Serbia. branko.beleslin@gmail.com.
Branko
B
Beleslin
Clinic for Cardiology, Clinical Center of Serbia, Visegradska 26, 11000, Belgrade, Serbia. ivana170679@gmail.com.
Ivana
I
Jovanovic
Clinic for Radiology, Clinical Center of Serbia, Belgrade, Serbia. anicak@yahoo.com.
Ana
A
Mladenovic
Medical School, University of Belgrade, Belgrade, Serbia. jpseferovic@gmail.com.|Clinic for Endocrinology, Clinical Center of Serbia, Belgrade, Serbia. jpseferovic@gmail.com.
Jelena
J
Seferovic
Medical School, University of Belgrade, Belgrade, Serbia. mostojic2003@yahoo.com.
Miodrag
M
Ostojic
Medical School, University of Belgrade, Belgrade, Serbia. drarandjelovic@yahoo.com.|Cardiology Department, Clinical Hospital Zvezdara, Belgrade, Serbia. drarandjelovic@yahoo.com.
Aleksandra
A
Arandjelovic
D058070:Asymptomatic Diseases / Q000401:mortality; D002114:Calcinosis / Q000150:complications / Q000000981:diagnostic imaging* / Q000401:mortality* / Q000503:physiopathology; D015984:Causality; D015897:Comorbidity; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000401:mortality* / Q000503:physiopathology; D048909:Diabetes Complications / Q000000981:diagnostic imaging / Q000401:mortality* / Q000503:physiopathology; D004452:Echocardiography / Q000706:statistics & numerical data; D005260:Female; D053805:Fractional Flow Reserve, Myocardial; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods; D012680:Sensitivity and Specificity; D055771:Serbia; D012720:Severity of Illness Index; D015996:Survival Rate