Purpose
Coronary computed tomographic angiography (CTA) is a valuable tool for assessing coronary artery disease (CAD). Although statin use is widely recommended for persons with diabetes older than age 40, little is known about the presence and severity of CAD in younger patients with diabetes mellitus (DM). We evaluated coronary artery calcium (CAC) and coronary CTA in young persons with both DM1 and DM2 in an attempt to detect the earliest objective evidence of arteriosclerosis eligible for primary prevention.
Methods and Materials
We prospectively enrolled 40 persons with DM (25 type 1 and 15 type 2) between the ages of 19 and 35 presenting with diabetes for 5 years or longer. All patients underwent coronary CTA and CAC scans to evaluate for early atherosclerotic disease. Each plaque in the coronary artery was classified as noncalcified or calcified-mixed. We also evaluated all segments with stenosis, dividing them into mild (<50%), moderate (50–70%), and severe (>70%).
Results
The average age of the DM1 subjects were 26 ± 4 (SD) years and 30 ± 4 years for DM2 patients ( P < .01), with duration of diabetes of 8 ± 5 years and average HbA1c% of 8.7 ± 1.6 (norm = 4.6–6.2). Abnormal scans were present in 57.5%, noncalcified in 35% and calcified-mixed plaque in 22.5%. Persons with DM2 had a higher prevalence of positive coronary CTA scans than DM1: 80% versus 44% ( P < .03) and more positive CAC scores 53% versus 4%, ( P < .01). The total segment score of 2.1 ± 3.4 (P < .01) and total plaque score 1.9 ± 2.8 ( P < .01) were highly correlated to each other. Plaque was almost uniformly absent below age 25, and became increasingly common in individuals over the age of 25 years for both groups. The average radiation exposure was 2.5 ± 1.3 mSv.
Conclusion
Our study verifies that early CAD can be diagnosed with coronary CTA and minimal radiation exposure in young adults with DM. A negative CAC score was not sufficient to exclude early CAD as we observed a preponderance of noncalcified plaque in this cohort. Coronary CTA in young DM patients older than age 25 may provide earlier identification of disease than does a CAC because only noncalcified plaque is frequently present. Coronary CTA provides an opportunity to consider initiation of earlier primary CAD prevention rather than waiting for the age of 40 as currently recommended by the American Diabetes Association guidelines.
Cardiovascular disease is the leading cause of death in persons with diabetes . Cholesterol-lowering therapy has been demonstrated to reduce cardiovascular events in these patients . Current lipid management strategies in individuals with diabetes target low-density lipoprotein (LDL) lowering predominantly in those older than age 40. These strategies give way to decreasing macrovascular disease and mortality, especially in those with a history of cardiovascular events . Studies have shown that adults with diabetes who take statins and other lipid-lowering agents are able to reduce both coronary and cerebrovascular events . There are few data to support lipid-lowering therapy (eg, statins) use in asymptomatic persons with diabetes <40 years of age. The current guidelines state that persons with diabetes <40 years without cardiovascular disease who cannot achieve lipid goals alone with lifestyle modifications, but who are at increased risk because of other cardiovascular risk factors or duration of diabetes, should consider pharmacological therapy if LDL cholesterol is >100 mg/dL . Noninvasive computed tomography (CT) plaque imaging is able to identify the presence and extent of noncalcified atherosclerotic plaque in obese children . Previously, high radiation doses precluded use of coronary CT angiography (CTA) in younger patients; however, significant dose-reduction techniques have led to radiation doses that are lower than annual background radiation exposure . We evaluated coronary artery calcium (CAC) and coronary CTA in young persons with type 1 and 2 diabetes (DM1 and DM2) in an attempt to detect evidence of arteriosclerosis eligible for primary prevention. We also looked at lipid subfractions and its association with coronary CTA plaque prevalence in persons with diabetes.
Methods and materials
We prospectively enrolled 40 volunteers with diabetes (25 type 1 and 15 type 2) between the ages of 19 and 35 presenting with diabetes for 5 years or longer in the South Los Angeles area. Patients were recruited from the diabetes clinic at Harbor-UCLA Medical Center and the offices of Cardiovascular Medical Group of Southern California, Beverly Hills California, after signed informed consent. All patients underwent coronary CTA and CAC scans to evaluate for early atherosclerotic disease. Lipid subfractions and CAC scores were determined for each patient. The average radiation exposure was 2.48 ± 1.3 mSv.
CAC Scanning
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64-multidetector CT Imaging Procedure
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CT Angiography Image Acquisition
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Coronary CTA Interpretation
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Plaque Severity Score
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Segment Stenosis Scoring
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Results
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Table 1
Demographics of Study Population in Relation to Type I and II Diabetes
Variable Type I Diabetes ( n = 25) Type II Diabetes ( n = 15)P Value Age 26 ± 4 y 30 ± 4 yrs <.01 Glucose 206.9 ± 86.7 mg/dL 175.3 ± 85.8 mg/dL >.01 HgA1c% 9.0 ± 1.3% 7.9 ± 2.1% >.01 Triglycerides 107.2 ± 107.6 mg/dL 192.5 ± 165.1 mg/dL <.06 HDL2 14.5 ± 9.2 mg/dL 9.5 ± 5.1 mg/dL <.05 VLDL3 10.5 ± 2.4 mg/dL 13.0 ± 4.1 mg/dL <.05 Hs-CRP 3.6 ± 7.1 mg/L 19.3 ± 27.0 mg/L <.05
HDL, high-density lipoprotein; HsCRP, high-sensitivity C-reactive protein; HgAIC, hemoglobin A1c; VLDL, very low density lipoproteins.
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Discussion
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Limitations
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Conclusion
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Acknowledgment
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