A Novel and Practical Screening Tool for the Detection of Silent Myocardial Infarction in Patients With Type 2 Diabetes.
Silent myocardial infarction (MI) is a prevalent finding in patients with type 2 diabetes and is associated with significant mortality and morbidity. Late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR) is the most validated technique for detection of silent MI, but is time-consuming, costly, and requires administration of intravenous contrast. We therefore planned to develop a simple and low-cost population screening tool to identify those at highest risk of silent MI validated against the CMR reference standard.



A total of 100 asymptomatic patients with type 2 diabetes underwent electrocardiogram (ECG), echocardiography, biomarker assessment, and CMR at 3.0T including assessment of left ventricular ejection fraction and LGE. Global longitudinal strain from two- and four-chamber cines was measured using feature tracking.



A total of 17/100 patients with no history of cardiovascular disease had silent MI defined by LGE in an infarct pattern on CMR. Only four patients with silent MI had Q waves on ECG. Patients with silent MI were older (65 vs 60, P = .05), had lower E/A ratio (0.75 vs 0.89, P = .004), lower GLS (-15.2% vs -17.7%, P = .004), and higher amino-terminal pro brain natriuretic peptide (106 ng/L vs 52 ng/L, P = .003). A combined risk score derived from these four factors had an area under the receiver operating characteristic curve of 0.823 (0.734-0.892), P < .0001. A score of more than 3/5 had 82% sensitivity and 72% specificity for silent MI.



Using measures that can be derived in an outpatient clinic setting, we have developed a novel screening tool for the detection of silent MI in type 2 diabetes. The screening tool had significantly superior diagnostic accuracy than current ECG criteria for the detection of silent MI in asymptomatic patients.
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Peter P
PP
Swoboda
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Adam K
AK
McDiarmid
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Bara
B
Erhayiem
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Philip
P
Haaf
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Ananth
A
Kidambi
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Graham J
GJ
Fent
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Laura E
LE
Dobson
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Tarique A
TA
Musa
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Pankaj
P
Garg
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Graham R
GR
Law
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Mark T
MT
Kearney
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Julian H
JH
Barth
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Ramzi
R
Ajjan
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
John P
JP
Greenwood
Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine (P.P.S., A.K.M., B.E., P.H., A.K., G.J.F., L.E.D., T.A.M., P.G., M.T.K., R.A., J.P.G., S.P.), University of Leeds, Leeds, United Kingdom; Leeds Teaching Hospitals NHS Trust (A.K., J.H.B.), Leeds, United Kingdom; Division of Epidemiology and Biostatistics (G.R.L.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Sven
S
Plein
D000368:Aged; D015415:Biomarkers / Q000378:metabolism*; D003287:Contrast Media; D048909:Diabetes Complications / Q000175:diagnosis* / Q000209:etiology / Q000378:metabolism; D003924:Diabetes Mellitus, Type 2 / Q000150:complications*; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D005682:Gadolinium; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008403:Mass Screening / Q000379:methods* / Q000592:standards*; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000209:etiology / Q000378:metabolism; D011379:Prognosis; D012372:ROC Curve
D015415:Biomarkers; D003287:Contrast Media; D005682:Gadolinium