Paper :: Prevention
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Transcript of Paper :: Prevention
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Cardiac Outcomes After Screening for Asymptomatic Coronary Artery Disease in Patients With Type 2 DiabetesThe DIAD Study: A Randomized Controlled Trial
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PAPER :: Prevention The Detection of Ischemia in
Asymptomatic Diabetics (DIAD study) JAMA. 2009;301(15):1547-1555
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CONTEXT Coronary artery disease (CAD) : major
cause of mortality and morbidity in patients with type 2 DM Often asymptomatic until MI or sudden cardiac
death Type 2 DM = CAD risk equivalent Current standard of care emphasizes the reduction
of cardiovascular risk factors But the utility of screening patients with type
2 DM for asymptomatic CAD is controversial.
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ABOUT MPI – MYOCARDIAL PERFUSION IMAGING
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OBJECTIVE To assess whether routine screening for
CAD identifies patients with type 2 DM as being at high cardiac risk and whether it affects their cardiac outcomes.
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Method
Age 50-75 years Onset of type 2
DM occurred at age 30 years
No history of ketoacidosis
Angina pectoris or chest discomfort
Stress test or CAG within the prior 3 years
History of MI, heart failure, or coronary revascularization
Abnormal rest EKG results Pathological Q waves Ischemic (1 mm
depression) ST segments Deep negative T waves, or Complete LBBB
Inclusion criteria (3)
Exclusion criteria (7)
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Method
Any clinical indication for stress testing
Active bronchospasm precluding the use of adenosine
Limited life expectancy due to cancer or end-stage renal or liver disease
Exclusion criteria (7)
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เหลือ1,700 เขา้รว่ม 1,123 (66%) 14 centers in USA and Canada
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Method Between July 2000 and August 2002. (25 month) DIAD protocol The study design and procedures were explained
by a member of the local research team All participants
History : health status, medications, intervening cardiac events, additional stress testing, CAG, and revascularizationat 6-month intervals
Physical examination : diabetic neuropathy, cardiac autonomic dysfunction
Lab : Blood and urine laboratory testing
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Method Randomization
Sequential identification number at each site A corresponding sealed envelope was opened Random permuted blocks (block size 6)
sequence 1:1
561 participants was screening with adenosine Tc-99m sestamibi MPI, interpreted by nuclear cardiologists
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METHOD - Cardiac event
Nonfatal MI Cardiac death-
included fatal MI (within 30 days)
Death due to heart failure or arrhythmia
Sudden cardiac death
Unstable angina Heart failure Stroke Coronary
revascularization
Primary end point Secondary end points
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METHOD – Statistic analysis
Data Statistic analysis
SAS statistical software version 9.1Bivariate associations, according to loss F/U, randomization status, and factors associated with cardiac events
t testsWilcoxon Rank sum, 2, and Fisher
Changes in medications McNemar test and logistic regression.
Hazard ratios (HRs) comparing(1)Events in screened vs
nonscreened(2)Events in participants with
normal MPI vs nonperfusion, small or moderate or large perfusion defects
Cox proportional hazards regression
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Was the assignment of patients to screening randomised ?1A – YesNoUnclear
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Were measures objective or were the patients and clinicians kept “blind” to which treatment was being received?
3 – YesNoUnclear
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RESULT Mean (SD) 4.8 (0.9) years Median 5 years F/U was complete 97% at 3.5
years Last data collected in Sep 2007
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RESULTBaseline characteristic overview
Age DM duration (year) BMI HbA1C Serum creatinine Clinical risk factor Gender Race DM treatment DM complication Current smoking Family history of
premature CAD
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Were the groups similar at the start of the trial?1B – YesNoUnclear
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Aside from the allocated screened, were groups screened equally?
2A – YesNoUnclear
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Were all patients who entered the trial accounted for? – and were they analysed in the groups to which they were randomised?
2B – YesNoUnclear
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RESULT :: Primary outcomes
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RESULT :: Primary outcomes
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RESULT :: Primary outcomes
32 cardiac event (17 MI + 15 cardiac death)
Overall cumulative 5-year cardiac event rate = 2.9 % (average 0.6% per year)
Hazard ratio = 0.88; 95% CI 0.44-1.8; log-rank 0.12; P =
0.73
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RESULT :: Primary outcomes
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RESULT :: Primary outcomes
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RESULT :: Primary outcomes
Mean (SD) MPI defect size [P = 0.12] Cardiac event 4.1% (6.6%) No cardiac event 1.4% (2.2%)
Negative predictive value of having a normal MPI = 98% (401of 409).
Positive predictive value 6% (7 of 113) of patients for any MPI
abnormality 12% (4 of 33) of patients for moderate or
large MPI defects.
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Cardiac event +ve
Cardiac event - ve
Test + ve 7 106
Test - ve 8 401
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RESULT :: Secondary outcomes
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RESULT :: Secondary outcomesCoronary angiography and revascularization
Repeat stress MPI 3 year (n = 358) : improved
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RESULT :: Secondary outcomesMedical treatment
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RESULT :: Secondary outcomesPredictors of cardiac events
Male sex Diabetes duration Microalbuminuria/proteinuria Serum creatinine Symptomsof peripheral
neuropathy Diminished peripheral
sensation Cardiac autonomic
dysfunction Peripheral vascular disease Elevated LDL Family history of premature
CAD
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Independent role of Male sex Serum creatinine Cardiac autonomic dysfunction Peripheral vascular disease LDL level
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How large was the screening effect?Re1– YesNoUnclear
Hazard Ratio =0.88Relative Risk = 2.7%/3.0% = 0.9Absolute Risk Reduction = 3.0%-2.7% = 0.3%Relative Risk Reduction = 1.0-0.9 = 0.1 or 10%Number Needed to Screen = 1/0.003 = 333
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How precise was the estimate of the treatment effect?Re2– YesNoUnclear
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COMMENT Cardiac event rates ในประชากรที่ศึกษา 0.6% per
year อัตราน้อยกวา่ท่ีคาดการณ์ไว้ เหน็ผลการเกิด cardiac event
จากการคัดกรองได้ไมช่ดัเจน อัตราต่ำ่ากวา่บางการศึกษาอ่ืนท่ีมมีาก่อน (retrospective
analysis; cardiology laboratories) 3-4 เท่า เนื่องจาก ประชากรในการศึกษาอ่ืนนัน้ๆ มี risk มากกวา่
อัตราใกล้เคียงกับ 3 การศึกษาในการ screening asymptomatic ischemia in type 2 DM
ACCORD study = 1.4% per year มกีารก่ำาหนด primary outcome definition, selection older patient with specific additional risk
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COMMENT ความผิดปกติท่ีตรวจพบจากการท่ำา MPI สมัพนัธกั์บ
อุบติัการณ์การเกิด cardiac event แมว้า่จะมี PPV ต่ำ่า และยงัมโีอกาสเกิด cardiac event ได้แมใ้นคนท่ี ผล MPI ปกติ
Cardiac outcomes ท่ีดี เกิดจาก Aggressive guideline-driven management
of cardiac risk factor การ screen ซ่ำ้าท่ี 3 ปี พบวา่มี resolution of
inducible ischemia
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COMMENT ผู้ป่วยท่ีคาดวา่จะมี intermediate cardiac risk
Long-standingdiabetes Older age Obesity
ผู้ป่วยท่ีคาดวา่จะมี high cardiac risk Poor ability to exercise
จากผล PPV, NPV พบวา่มากกวา่ครึง่หน่ึงของcardiac event เกิดใน normal screening test
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LIMITATIONS Cardiac event rates were significantly lower than
originally anticipated at the time of the design of the study
Not have the power to exclude a small difference between the screened and unscreened participants
Non protocol stress tests were done during F/U when clinically indicated in both groups
Screening led to only a modest reduction in subsequent diagnostic testing
In no-screening group : crossover to a physician-direct screening strategy and theoretically
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Clinical implications Routine screening for inducible ischemia in
asymptomatic patients with type 2 DM cannot be advocated Yield of detecting significant inducible
ischemia is relatively low. Overall cardiac event rate is low. Routine screening does not appear to affect
overall outcome. Routine screening of millions of asymptomatic
diabetic patients would be prohibitively expensive
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(External Validity/Applicability)
Will the results help me in caring for my patient?
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Screening criteriaCriteria This study
The burden of sufferingDeath, Disease, Disability, Discomfort, Dissatisfaction, Destitution
The quality of screening testSensitivity and specificity, Simplicity, Safety, CostEffectiveness of TreatmentCost-effectivenessLongevity
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