Miller Todd D, Redberg Rita F, Wackers Frans J T
Mayo Clinic, Rochester, Minnesota 55901, USA.
J Am Coll Cardiol. 2006 Aug 15;48(4):761-4. doi: 10.1016/j.jacc.2006.04.076. Epub 2006 Jul 24.
Given the elevated risk of cardiovascular events and the higher prevalence of silent coronary artery disease (CAD) in diabetic versus non-diabetic patients, screening asymptomatic diabetic patients for CAD is an appealing concept. However, many factors argue against implementing a broad-based screening program at the present time. Foremost is the lack of any published data demonstrating that a prospectively applied screening program improves outcome in asymptomatic diabetic patients. The true prevalence of CAD, and in particular prognostically important CAD, in this population is uncertain. Consensus documents recommend more aggressive treatment of hypertension and hyperlipidemia solely on the basis of diabetes status, without differentiation based on the presence or absence of identifiable CAD. There is no evidence that use of anti-ischemic medication can alter the natural history of CAD in these patients. Retrospectively performed studies using stress single-photon emission computed tomography (SPECT) imaging have reported that approximately 50% and 20% of patients have abnormal and high-risk images, respectively. However, the only prospectively designed study, the DIAD (Detection of Ischemia in Asymptomatic Diabetics) study, reported a much lower percentage of abnormal SPECT images (16%) and images with a very large (>/=10% of the left ventricle) defect (1%). The financial implications of screening all asymptomatic diabetic patients determined to be at intermediate and high risk by clinical scoring systems is enormous. Clearly more data are needed to address this issue. Future studies should consider possible methods to enrich the patient subset that might benefit from screening and should include carefully performed cost-effective analyses.
鉴于糖尿病患者心血管事件风险升高以及无症状冠状动脉疾病（CAD）患病率高于非糖尿病患者，对无症状糖尿病患者进行CAD筛查是一个有吸引力的概念。然而，目前有许多因素反对实施广泛的筛查计划。首要的是缺乏任何已发表的数据表明前瞻性应用的筛查计划能改善无症状糖尿病患者的预后。该人群中CAD的真实患病率，尤其是对预后有重要意义的CAD的患病率尚不确定。共识文件建议仅根据糖尿病状态更积极地治疗高血压和高脂血症，而不根据是否存在可识别的CAD进行区分。没有证据表明使用抗缺血药物可以改变这些患者CAD的自然病程。使用负荷单光子发射计算机断层扫描（SPECT）成像进行的回顾性研究报告称，分别约有50%和20%的患者图像异常和具有高风险。然而，唯一一项前瞻性设计的研究，即DIAD（无症状糖尿病患者缺血检测）研究，报告的异常SPECT图像百分比（16%）和有非常大（≥左心室的10%）缺损的图像百分比（1%）要低得多。通过临床评分系统确定对所有无症状糖尿病中高危患者进行筛查的经济影响巨大。显然需要更多数据来解决这个问题。未来的研究应考虑可能的方法来富集可能从筛查中受益的患者亚组，并应包括精心进行的成本效益分析。
