Coronary artery calcium (CAC) screening is the best non-invasive tool for measuring the risk of cardiovascular disease in asymptomatic patients with diabetes, according to a state-of-the-art paper from ACC’s Imaging Council published Feb. 1 in JACC: Cardiovascular Imaging. 

The Council examined all screening tools currently used for risk assessment in patients with diabetes, including stress testing, carotid intima-media thickness, CAC screening, echocardiography, radionuclide imaging, coronary computed tomography angiogram (CTA) and cardiac magnetic resonance imaging.

Current guidelines support risk factor assessment, CAC scanning and hemoglobin A1c for risk assessment, but not carotid intima-media thickness or routine function tests in asymptomatic diabetic patients. These patients are considered to be at high risk for coronary artery disease, for which exercise electrocardiogram is rated “appropriate” and stress radionuclide imaging, stress echocardiography, stress cardiac magnetic resonance, calcium scoring and coronary CTA are all rated “may be appropriate.”

According to the authors, patients with type-2 diabetes have higher amounts of CAC than nondiabetic patients, but a high proportion of adults with diabetes have a CAC score of 0 or very low. They explain that CAC provides strong risk stratification of these patients, with an increase in mortality for each increase in CAC score category. Mortality risks are higher for each CAC category in patients with diabetes compared to those without. Patients with rapid progression of CAC are at a higher risk of coronary heart disease events.

“CAC screening offers the most sensitive noninvasive risk stratification tool among asymptomatic persons with [diabetes],” the Council writes. “However, although this approach has been shown to improve the stratification of persons with [diabetes], it has not yet been shown to result in improved outcomes. This is a knowledge gap that needs to be addressed with clinical trials.”

Keywords: Carotid Intima-Media Thickness, Coronary Artery Disease, Diabetes Mellitus, Echocardiography, Echocardiography, Stress, Electrocardiography, Exercise Test, Glycated Hemoglobin A, Magnetic Resonance Imaging, Magnetic Resonance Spectroscopy, Radioisotopes, Risk Assessment, Risk Factors, Tomography

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