Value of Coronary Computed Tomography Angiography in Tailoring Aspirin Therapy for Primary Prevention of Atherosclerotic Events in Patients at High Risk With Diabetes Mellitus.

Aspirin use for primary prevention in patients at high risk with diabetes mellitus (DM) is often recommended under the assumption that most patients with DM have coronary artery disease (CAD). However, not all patients may have CAD. The present study evaluated, in 425 patients at high risk with DM (without chest pain syndrome or a history of cardiac disease), the prevalence of CAD on coronary computed tomography angiography (CTA). Moreover, the association between the presence and number of traditional cardiovascular (CV) risk factors and CAD (on coronary CTA) was evaluated. The median coronary artery calcium score was 29 (interquartile range 0 to 298). On coronary CTA, 116 patients (27%) had no CAD (defined as <30% stenosis). Of the 309 patients (73%) with any CAD (≥30% stenosis), 35% had obstructive CAD (≥50% stenosis). The number of traditional CV risk factors was not associated with the presence of any CAD (≥30% stenosis; p = 0.18) or obstructive CAD (≥50% stenosis; p = 0.13). Hypertension was the only traditional CV risk factor associated with a higher frequency of any CAD (≥30% stenosis; odds ratio = 2.21, 95% CI 1.43 to 3.41, p <0.001) and obstructive CAD (≥50% stenosis; odds ratio 2.03, 95% CI 1.33 to 3.11, p = 0.001). In conclusion, in patients at high risk with DM without chest pain syndrome, any CAD was ruled out by coronary CTA in 27%, whereas 65% of the patients did not have obstructive CAD. The number of CV risk factors was not associated with the presence of CAD. Hypertension was the only traditional CV risk factor that was associated with a higher frequency of CAD. These observations support potential use of coronary CTA to tailor aspirin therapy in patients at high risk with DM.

Comparison by computed tomographic angiography-the presence and extent of coronary arterial atherosclerosis in South Asians versus Caucasians with diabetes mellitus.

South Asians in the Western world have a high prevalence of diabetes mellitus (DM) and an increased risk of coronary artery disease (CAD) and mortality compared with Caucasians. CAD in asymptomatic South Asian patients with type 2 DM has not been investigated. The aim of this observational cohort study was to investigate CAD in asymptomatic South Asian patients with type 2 DM and to compare with matched Caucasian patients. A total of 120 asymptomatic South Asian patients with type 2 DM and matched Caucasian patients (mean age 52 years, 55% men) were derived from an ongoing registry of cardiovascular risk stratification in asymptomatic patients with DM. Cardiovascular risk assessment included multidetector row coronary computed tomography angiography. CAD was assessed as the coronary artery calcium score and classified into no signs of atherosclerosis or minor wall irregularities <30%, nonsignificant CAD 30% to 50%, or significant CAD ≥50% stenosis. On a patient base, CAD was scored according to the severity and number of vessels and segments with significant CAD. Subsequently, CAD was assessed per coronary artery and per segment. Compared with Caucasian patients, South Asian patients had a significantly higher coronary artery calcium score and higher prevalence of significant CAD (41% vs 28%, respectively, p = 0.008), involving more coronary vessels and segments. Significant CAD was especially more frequent in the left anterior descending coronary artery. In conclusion, asymptomatic South Asian patients with type 2 DM have a higher prevalence and extent of CAD compared with matched Caucasian patients.

Changes in multidirectional LV strain in asymptomatic patients with type 2 diabetes mellitus: a 2-year follow-up study.

AIMS: Asymptomatic patients with diabetes mellitus (DM) and normal left ventricular (LV) ejection fraction (EF) may have LV dysfunction as assessed with speckle tracking echocardiography. Whether this subtle LV dysfunction may progress or not over time remains unknown. The present evaluation assessed changes in LV function with two-dimensional (2D) speckle tracking analysis in asymptomatic clinically stable patients with type 2 DM and normal LVEF after 2-year follow-up. METHODS AND RESULTS: A total of 112 asymptomatic patients with type 2 DM and normal LVEF (53 ± 10 years, 59% men) were evaluated. Patients remained clinically stable between baseline and follow-up echocardiography. Conventional and 2D speckle tracking echocardiographic measurements were performed. Circumferential strain (CS) and longitudinal strain (LS) were measured to assess systolic function and strain rate during isovolumetric relaxation time (SR IVR) and peak transmitral early diastolic inflow strain rate (SR E) to assess diastolic function. After 2-year follow-up, a significant increase in the LV mass index and significant decrease in the E/A ratio were observed. Left ventricular ejection fraction remained unchanged (59 to 60%, P = 0.4). In contrast, 2D speckle tracking analysis demonstrated a significant impairment in CS (-19.7 ± 4.0 to -18.9 ± 3.8%, P < 0.001), LS (-17.2 ± 2.3 to -16.9 ± 2.7%, P = 0.022), and SR E (from 1.02 ± 0.28 to 0.94 ± 0.25 S(-1), P < 0.001). After adjusting for changes in the LV mass index, only changes in CS and SR E remained significant (P < 0.001 and P = 0.013, respectively). CONCLUSION: Asymptomatic patients with type 2 DM and normal LVEF may show mild progression of subclinical LV function assessed with 2D speckle tracking echocardiography. The prognostic implications of these mild changes warrant prospective evaluation.

Incidence of recombinant erythropoietin (EPO) hyporesponse, EPO-associated antibodies, and pure red cell aplasia in dialysis patients.

BACKGROUND: Since 1998, an increase of anti-erythropoietin (anti-EPO) antibody-induced pure red cell aplasia (PRCA) has been reported. As data up to now consisted mostly of spontaneously reported cases the question arose about the frequency of this increase in EPO-induced PRCA. The objectives of this study were to determine the incidence and causes of recombinant EPO hyporesponse, of antibodies to EPO in patients on dialysis, and to relate the detection of anti-EPO antibodies to the presence of PRCA. METHOD: This multicenter cohort study used existing patient data and serum samples collected at 6-month intervals from 1677 patients with incident end-stage renal disease (ESRD) participating in The Netherlands Cooperative Study on the Adequacy of Dialysis-2 (NECOSAD-2). RESULTS: Fifty-seven patients had an inadequate EPO response, which resulted in an incidence of 16.7 per 1000 patient-years on EPO while on dialysis. All available sera specimens (N = 232) of these patients were screened for anti-EPO antibodies. The sera specimens of two of these 57 patients tested positive. Of the 57 patients with inadequate EPO response, one had clinical PRCA (incidence 0.29 per 1000 patient-years on EPO and on dialysis). Of the 1346 patients without symptoms of inadequate EPO response, one patient tested borderline positive for anti-EPO antibodies. In total, three patients developed EPO antibodies during follow-up, leading to an estimated incidence of 1.27/1000 (95% CI 0.3 to 3.7/1000) patient-years since the start of dialysis. CONCLUSION: The incidence of inadequate EPO response in our population of dialysis patients is in concordance with tentative calculations found in the literature. Furthermore, we found the incidence of EPO-induced PRCA and EPO antibodies to be low.