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Risk Stratification and Prognosis of Diabetics Without History of Coronary Artery Disease by Dobutamine Stress Echocardiogram

Bridgeport Hospital, Fairfield, CT

PURPOSE: Diabetics without a history of coronary artery disease (CAD) are known to have worse outcomes than non-diabetics and are often asymtomatic. There is a need for non invasive methods to identify these asymptomatic high risk patients who have established CAD. In this study we examined the role of DSE in risk stratifying and prognosticating diabetics without known CAD, as the data is limited.

METHODS: We compared 488 non diabetics to 200 diabetic patients referred for DSE. Patients with prior myocardial infarction, percutaneous coronary intervention or coronary artery bypass graft were excluded. Echocardiograms were read by two experienced readers.Wall motion analysis was performed using a standard 16-segment model. Resting wall motion score index (RWMI) was calculated. Ischemia was defined as new reversible wall motion abnormality and/or biphasic response. Five-year follow up was obtained for MI and cardiac death.

RESULTS: Baseline parameters of diabetics and non diabetics were similar except for mean LVEF of 50 ± 15% vs. 55% ± 11, P = 0.002. Higher percentage of diabetics as compared to nondiabetics had RWMI >1 (38% vs. 25%, P = 0. 006), ischemia (26.5% vs. 14.8%, P = 0.003) and annual hard event rate (1.2% vs. 0.58%, P value = 0.01). Among diabetics, 56.6% with RWMI>1 had ischemia that was associated with a 2.7% annual hard event rate. Diabetics with ischemia by DSE had lower LVEF compared to non diabetics(34 ± 16 % vs. 56 ± 9%, P< 0.0001). In multivariate logistic regression analysis, ischemic diabetics were more likely to develop a hard event as compared to nonischemics, after controlling for LVEF and known risk factors for CAD (OR 6.5, 95% CI: 1.7, 24.7).

CONCLUSION: DSE is useful in risk-stratifying and prognosticating diabetics without history of CAD. Diabetics who have ischemia by DSE have a poor prognosis as compared to those without ischemia.

CLINICAL IMPLICATIONS: This study demonstrates the usefulness of DSE in identifying high risk diabetics.

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