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The figure shows the relationship between increasing Further development in novel bio-markers may help
coronary artery score (EBCT) and the ‘total ishcaemic’ earlier detection of diabetic patients at higher risk of
burden from the sestamibi SPECT myocardial perfu- developing coronary atherosclerosis. Osteoprotegrin
sion imaging, showing a close relationship between is an interesting biomarker which has been linked to
increasing CAC score and size and severity of the increasing CAC scores in diabetes. This type of ‘mod-
perfusion abnormality. elling’, where one combines risk factors, bio-mark-
ers, CT and functional imaging, may provide a more
Based on these trials there is now strong evidence cost-effective and accurate method of detecting
that that coronary artery calcium imaging may be those at risk. (Ref 5 and 6)
beneficial in diabetic patients with moderate to high
cardiovascular risk factors.
References
current Guidelines and Future Trends: 1. Haffner SM1, Lehto S, Rönnemaa T, Pyörälä K, Laakso M.Mortality from
coronary heart disease in subjects with type 2 diabetes and in nondiabetic
According to the 2010 ACC/AHA Guidelines for as- subjects with and without prior myocardial infarction. N Engl J Med. 1998;
sessment of CV risk, in asymptomatic adults with 23: 339(4):229-34.
diabetes, 40 years of age and older, measurement 2. Raggi P, Shaw LJ, Berman DS, Callister TQ. Prognostic value of coronary
of CAC is reasonable for cardiovascular risk assess- artery calcium screening in subjects with and without diabetes. J Am Coll
ment (Class IIa B). The 2012 European Guideline for Cardiol2004;43:1663–1669.
CV risk assessment also acknowledges that Com- 3. Budoff MJ, Shaw LJ, Liu ST, et al. Long-term prognosis associated with
puted tomography for coronary calcium should be coronary calcification: observations from a registry of 25,253 patients. J
considered for cardiovascular risk assessment in as- Am Coll Cardiol. 2007. 49(18):1860-70.
ymptomatic adults at moderate risk. (IIa) 4. Anand DV, Lim E, Hopkins D, et al. Risk stratification in uncomplicated
type 2 diabetes: prospective evaluation of the combined use of coronary
The 2013 ACC/AHA Guideline on the Assessment artery calcium imaging and selective myocardial perfusion scintigraphy. Eur
of Cardiovascular Risk clearly states that “assessing Heart J. 2006 ,27(6):713-21.
CAC is likely to be the most useful of the current 5. Anand DV, Lahiri A, Lim E et al. The Relationship BetweenPlasma Osteo-
approaches to improving risk assessment among in- protegerin Levels and CoronaryArteryCalcification in Uncomplicated Type
dividuals found to be at intermediate risk after formal 2 Diabetic Subjects. J Am Coll Cardiol2006;47:1850–7
risk assessment.”

Conclusion:
The number of patients with diabetes type 2 will in-
crease dramatically over the next few decades. For
adequate risk stratification, assessment of coronary
artery atherosclerosis would be advantageous. In as-
ymptomatic patients, screening for coronary artery
disease is less established. Although a substantial
number of patients may have silent ischemia, not
all patients may benefit from imaging to detect isch-
emia. Newer imaging modalities to detect sub-clinical
atherosclerosis in the form of CAC imaging and new-
er biomarkers help detect increased cardiovascular
risk may provide an important diagnostic modality.
CAC imaging provides excellent risk stratification in
patients with diabetes, with an increase in mortality
for each increase in CAC score category. The mortali-
ty risk is higher for each CAC category in the patients
with diabetes than in those without. However, about
40% of adult diabetic patients have a CAC score <10
and a very low mortality rate. Rapid progression of
CAC signifies patients at higher risk for CHD events.
The overall evidence supports the use of CAC scan-
ning for risk stratification and to guide management
in the asymptomatic DM patient.

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