Long-Term Prognostic Utility of Coronary CT Angiography in Stable Patients With Diabetes Mellitus

OBJECTIVES: The goal of this study was to determine the long-term prognostic value of coronary computed tomography angiography (CTA) among patients with diabetes mellitus (DM) compared with nondiabetic subjects. The long-term prognostic value of coronary CTA in patients with DM is not well established.

METHODS: Patients enrolled in the CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) registry with 5-year follow-up data were identified. The extent and severity of coronary artery disease (CAD) were analyzed at baseline coronary CTA and in relation to outcomes between diabetic and nondiabetic patients. CAD according to coronary CTA was defined as none (0% stenosis), nonobstructive (1% to 49% stenosis), or obstructive (≥50% stenosis). Time to death (and in a subgroup, time to major adverse cardiovascular event) was estimated by using multivariable Cox proportional hazards models.

RESULTS: A total of 1,823 patients were identified as having DM with 5-year clinical follow-up and were propensity-matched to 1,823 patients without DM (mean age 61.8 ± 10.9 years; 54.4% male). Patients with DM did not exhibit a heightened risk of death compared with the propensity-matched nondiabetic subjects in the absence of CAD on coronary CTA (risk-adjusted hazard ratio [HR] of DM: 1.32; 95% confidence interval [CI]: 0.78 to 2.24; p = 0.296). Patients with DM were at increased risk of dying compared with nondiabetic subjects in the setting of nonobstructive CAD (in the propensity-matched cohort: HR, 2.10; 95% CI: 1.43 to 3.09; p < 0.001) with a mortality risk greater than nondiabetic subjects with obstructive disease (p < 0.001). In a risk-adjusted hazard analysis among patients with DM, both per-patient obstructive CAD and nonobstructive CAD conferred an increase in all-cause mortality risk compared with patients without atherosclerosis on coronary CTA (nonobstructive disease—HR: 2.07; 95% CI: 1.33 to 3.24; p = 0.001; obstructive disease—HR: 2.22; 95% CI: 1.47 to 3.36; p < 0.001).

CONCLUSIONS: Among patients with DM, nonobstructive and obstructive CAD according to coronary CTA were associated with higher rates of all-cause mortality and major adverse cardiovascular events at 5 years, and this risk was significantly higher than in nondiabetic subjects. Importantly, patients with DM without CAD according to coronary CTA were at a risk comparable to that of nondiabetic subjects.
Perspectives
COMPETENCY IN MEDICAL KNOWLEDGE: Both nonobstructive and obstructive CAD according to coronary CTA confers an increased long-term risk of MACE and mortality in patients with DM. Importantly, the risk in these patients is comparable to those with nonobstructive disease and obstructive coronary disease. In addition, patients with DM without atherosclerosis on coronary CTA have a good long-term prognosis that is comparable to that of nondiabetic subjects.

TRANSLATIONAL OUTLOOK: Coronary CTA uniquely provides important long-term risk stratification of patients with DM. The role of coronary CTA to stratify therapy according to presence or absence and extent of CAD needs further assessment. Tom Compton Womens Jersey

PMID:

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