title: Stratifying cardiovascular risk in diabetes: The role of diabetes-related clinical characteristics and imaging.
abstract: Diabetes is a major coronary heart disease (CHD) and cardiovascular disease (CVD) risk factor and has traditionally been classified as a CHD risk equivalent. CVD risk, however, is heterogeneous among diabetic patients and thus further evaluation is warranted before initiating or titrating preventive pharmacotherapy. Prognostic clinical characteristics of diabetes such as age of onset, duration, and severity of diabetes, as well as concomitant cardiometabolic factors account for much of the variability in CHD and CVD risk. This heterogeneity can also be evaluated directly using non-invasive imaging, which allows for a more individualized risk assessment in order to minimize both under and overtreatment. In this paper, we review guideline recommendations for atherosclerotic CVD risk assessment driving the use of statins or aspirin for certain subgroups of patients with diabetes. We further discuss imaging techniques, such as stress myocardial perfusion imaging, coronary computed tomography angiography, and coronary artery calcium (CAC) scoring that can guide the decision to treat high-risk patients. Among imaging tests, current guidelines consider CAC scoring the most appropriate risk stratification tool for asymptomatic individuals with diabetes that can guide initiating/intensifying or withholding the most aggressive pharmacological therapies among high-risk (CAC>100) or low-risk (CAC=0) individuals, respectively.
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA. Electronic address: skianou1@jhmi.edu.
authors.forename: Sina
authors.initials: S
authors.lastname: Kianoush
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA. Electronic address: malrifa1@jhu.edu.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Al Rifai
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA. Electronic address: swhelto1@jhmi.edu.
authors.forename: Seamus P
authors.initials: SP
authors.lastname: Whelton
authors.affiliation: Miller School of Medicine, University of Miami, FL, USA. Electronic address: geshaya@med.miami.edu.
authors.forename: Gabriel E
authors.initials: GE
authors.lastname: Shaya
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA. Electronic address: bush@jhmi.edu.
authors.forename: Aaron L
authors.initials: AL
authors.lastname: Bush
authors.affiliation: Aetna Foundation, Hartford, CT, USA; University of Connecticut School of Medicine, Farmington, CT, USA. Electronic address: grahamg@aetna.com.
authors.forename: Garth
authors.initials: G
authors.lastname: Graham
authors.affiliation: Division of Cardiology, University of California, Irvine, Irvine, CA, USA. Electronic address: ndwong@uci.edu.
authors.forename: Nathan D
authors.initials: ND
authors.lastname: Wong
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins, Baltimore, MD, USA. Electronic address: mblaha1@jhmi.edu.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Blaha
mesh_terms: D002318:Cardiovascular Diseases / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000453:epidemiology*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000453:epidemiology*; D003920:Diabetes Mellitus / Q000453:epidemiology*; D006801:Humans; D018570:Risk Assessment; D012307:Risk Factors
keywords: Cardiovascular disease; Coronary artery calcium; Coronary heart disease; Primary prevention; Risk assessment; Statins