Page 110 - Petelin, Ana, Nejc Šarabon, Boštjan Žvanut, eds. 2017. Zdravje delovno aktivne populacije ▪︎ Health of the Working-Age Population. Proceedings. Koper: Založba Univerze na Primorskem/University of Primorska Press
P. 110
avje delovno aktivne populacije | health of the working-age population 108 in our study was somewhat lower than the 22% observed in the DIAD study
(Wackers et al., 2004) but a bit greater than 15,7% obtained in an earlier study
from France (Janand-Delenne et al., 1999). However, the lower prevalence re-
ported in this earlier study likely reflects differences in patients selection. Sub-
jects were of younger age, with T1DM and T2DM and perfusion abnormalities
were assessed visually with somewhat less sensitive technique. Moreover, im-
agings were performed only if the initial exercise ECG stress test was abnormal
or equivocal. Thus, patients who would have had perfusion abnormalities were
likely missed. On the other hand, it should be noted that the prevalence of per-
fusion abnormalities in DIAD study is considerably higher than that reported
in our study, reflecting the results of adenosine perfusion imaging in a slightly
older sample of patients (50-75years).
In a recent study of silent CAD detection in a cohort of 102 asymptomat-
ic T2DM subjects (57±7years), attending 5 Italian outpatient clinics, a signifi-
cant higher prevalence of silent CAD was observed in subjects with abnormal
vs. normal ECG (23 vs. 4%; P=0.004), but not in subjects with high vs. low pre-
test silent CAD risk (14 vs. 9%; p=0.472). An abnormal ECG was defined to be
a strong, independent predictor of silent CAD (OR 8.9; CI 1.27-62.5; p=0.028) in
T2DM (Vigili de Kreutzenberg et al., 2017).
Our second goal was to identify predictors of MPI abnormalities. Demo-
graphics, traditional cardiac risk factors, diabetes complications, and biomark-
ers were analysed. Overall predictors of SMI in working-age cohort of T2DM
patients were post-stress LVEF drop ≥5% and NT-proBNP levels detected in
stress. In univariate analysis, only post-stress LVEF drop ≥5% was the factor
associated with moderate-to-large perfusion defects abnormalities that raise
substantial clinical concern. In working-age patients with diabetes, post-stress
LVEF drop showed to be an independent predictor of stress-induced ischemia
and increases the risk of subsequent cardiac events in T2DM patients. However,
a fall in LVEF is detectable also in patients with normal myocardial perfusion.
These findings suggest that a post-stress LVEF drop may be related to a spe-
cific diabetic cardiomyopathy in the absence of myocardial perfusion abnor-
malities. Diabetic complications such as retinopathy, nephropathy and neu-
ropathy showed not to be significantly associated with either test abnormality
or marked perfusion defects. In addition, traditional cardiac risk factors (male
gender, hypertension, smoking and family history, or dyslipidaemia), previous-
ly reported as risk factors for CAD and poor outcome (De Keyzer et al., 2011)
were not associated with SMI in working-age T2DM patients.
Conclusions
Prevalence of T2DM in working-age population is high and still rising in Eu-
rope. Both diabetes and pre-diabetic states are risk factors for CAD. Their emer-
gence starts many years before clinical events appear, developing silently, in
parallel with the progression from pre-diabetic status to T2DM (Alegria-Bar-
rero, 2014). Our study suggests that 18.2% of asymptomatic working-age pa-
(Wackers et al., 2004) but a bit greater than 15,7% obtained in an earlier study
from France (Janand-Delenne et al., 1999). However, the lower prevalence re-
ported in this earlier study likely reflects differences in patients selection. Sub-
jects were of younger age, with T1DM and T2DM and perfusion abnormalities
were assessed visually with somewhat less sensitive technique. Moreover, im-
agings were performed only if the initial exercise ECG stress test was abnormal
or equivocal. Thus, patients who would have had perfusion abnormalities were
likely missed. On the other hand, it should be noted that the prevalence of per-
fusion abnormalities in DIAD study is considerably higher than that reported
in our study, reflecting the results of adenosine perfusion imaging in a slightly
older sample of patients (50-75years).
In a recent study of silent CAD detection in a cohort of 102 asymptomat-
ic T2DM subjects (57±7years), attending 5 Italian outpatient clinics, a signifi-
cant higher prevalence of silent CAD was observed in subjects with abnormal
vs. normal ECG (23 vs. 4%; P=0.004), but not in subjects with high vs. low pre-
test silent CAD risk (14 vs. 9%; p=0.472). An abnormal ECG was defined to be
a strong, independent predictor of silent CAD (OR 8.9; CI 1.27-62.5; p=0.028) in
T2DM (Vigili de Kreutzenberg et al., 2017).
Our second goal was to identify predictors of MPI abnormalities. Demo-
graphics, traditional cardiac risk factors, diabetes complications, and biomark-
ers were analysed. Overall predictors of SMI in working-age cohort of T2DM
patients were post-stress LVEF drop ≥5% and NT-proBNP levels detected in
stress. In univariate analysis, only post-stress LVEF drop ≥5% was the factor
associated with moderate-to-large perfusion defects abnormalities that raise
substantial clinical concern. In working-age patients with diabetes, post-stress
LVEF drop showed to be an independent predictor of stress-induced ischemia
and increases the risk of subsequent cardiac events in T2DM patients. However,
a fall in LVEF is detectable also in patients with normal myocardial perfusion.
These findings suggest that a post-stress LVEF drop may be related to a spe-
cific diabetic cardiomyopathy in the absence of myocardial perfusion abnor-
malities. Diabetic complications such as retinopathy, nephropathy and neu-
ropathy showed not to be significantly associated with either test abnormality
or marked perfusion defects. In addition, traditional cardiac risk factors (male
gender, hypertension, smoking and family history, or dyslipidaemia), previous-
ly reported as risk factors for CAD and poor outcome (De Keyzer et al., 2011)
were not associated with SMI in working-age T2DM patients.
Conclusions
Prevalence of T2DM in working-age population is high and still rising in Eu-
rope. Both diabetes and pre-diabetic states are risk factors for CAD. Their emer-
gence starts many years before clinical events appear, developing silently, in
parallel with the progression from pre-diabetic status to T2DM (Alegria-Bar-
rero, 2014). Our study suggests that 18.2% of asymptomatic working-age pa-
