May 28, 2020
In everything that we do as clinicians, the search for better options, treatments, or paths for our patients is constant. For patients with type 2 diabetes mellitus (T2DM), this need for a better option regarding cardiovascular disease is profound.
Cardiologists have long understood that patients with T2DM are likely to experience more aggressive cardiovascular disease development and progression than are patients with other comorbidities. Publications focusing on the need to serve these patients better came back to back this month with a scientific statement from the American Heart Association and an expert analysis from the American College of Cardiology both focused on evaluating and managing these challenging patients.
One element that caught my attention in both publications was discussion and direction around improving identification of stable CAD in patients with T2DM, especially those with new onset of chest pain. Relying on data from ISCHEMIA, SCOT-HEART, and PROMISE, there is a clear message that the use of standard stress testing to diagnose CAD may not be the best option for these patients.
Much has been written about how the ISCHEMIA trial findings force clinicians to rethink the utility of systematic stress testing, especially in terms of risk stratification and identification of patients who may benefit from revascularization. Those same learnings become even more impactful as we consider that 41% of ISCHEMIA participants had diabetes.
PROMISE found that patients with T2DM who were assessed with coronary CTA had a much lower CV event rate than those assessed with functional stress testing, and the findings in SCOT-HEART for patients with T2DM echoed this same message. It appears that the combination of these and other data led to this recommendation in the AHA Scientific Statement published this month:
“Overall, CTA may provide an advantage over stress testing in the management of patients with T2DM and stable angina, mostly for its ability to diagnose non-obstructive CAD and therefore inform medical management.”
This move toward coronary CTA is in line with guidelines and guidance from clinical societies, provider organizations, and healthcare payers around the world. With all that is changing now, it seems reasonable to believe that the movement to coronary CTA for CAD diagnosis will become more pronounced as it uniquely provides a combination of diagnostic confidence, prognostic insights, patient-provider safety, and CT-derived lesion-specific physiology.