5.3.0.0 Screen­ing Asymp­tomat­ic Pa­tients

The screen­ing of asymp­tomat­ic pa­tients with high ASCVD risk is not rec­om­mend­ed (140), in part be­cause these high-‍risk pa­tients should al­ready be re­ceiv­ing in­ten­sive med­i­cal ther­a­py-an ap­proach that pro­vides sim­i­lar benefit as in­va­sive revas­cu­larization (141,142). There is also some ev­i­dence that silent is­chemia may re­verse over time, adding to the con­tro­ver­sy con­cerning ag­gres­sive screen­ing strate­gies (143). In prospec­tive stud­ies, coro­nary artery cal­ci­um has been es­tab­lished as an in­de­pen­dent pre­dic­tor of fu­ture ASCVD events in pa­tients with di­a­betes and is con­sis­tently su­pe­ri­or to both the UK Prospec­tive Di­a­betes Study (UKPDS) risk en­gine and the Fram­ing­ham Risk Score in pre­dict­ing risk in this pop­u­la­tion (144-146). How­ev­er, a ran­dom­ized ob­ser­va­tion­al trial demon­strat­ed no clin­i­cal benefit to rou­tine screen­ing of asymp­tomat­ic pa­tients with type 2 di­a­betes and nor­mal ECGs (147). De­spite ab­nor­mal my­ocar­dial per­fu­sion imag­ing in more than one in five pa­tients, car­diac out­comes were es­sen­tial­ly equal (and very low) in screened ver­sus un­screened pa­tients. Ac­cord­ing­ly, in­dis­crim­i­nate screen­ing is not con­sid­ered cost-‍ef­fec­tive. Stud­ies have found that a risk fac­tor–based ap­proach to the ini­tial di­ag­nos­tic eval­u­a­tion and sub­se­quent fol­low-‍up for coro­nary artery dis­ease fails to iden­tify which pa­tients with type 2 di­a­betes will have silent is­chemia on screen­ing tests (148,149).

Any benefit of newer nonin­va­sive coro­nary artery dis­ease screen­ing meth­ods, such as com­put­ed to­mog­ra­phy cal­ci­um scor­ing and com­put­ed to­mog­ra­phy an­giog­ra­phy, to iden­tify pa­tient sub­groups for dif­ferent treat­ment strate­gies re­mains un­proven in asymp­tomat­ic pa­tients with di­a­betes, though re­search is on­go­ing. Al­though asymp­tomat­ic pa­tients with di­a­betes with high­er coro­nary dis­ease bur­den have more fu­ture car­diac events (144,150,151), the role of these tests be­yond risk stratification is not clear.

While coro­nary artery screen­ing meth­ods, such as cal­ci­um scor­ing, may im­prove car­dio­vas­cu­lar risk as­sess­ment in peo­ple with type 2 di­a­betes (152), their rou­tine use leads to ra­di­a­tion ex­po­sure and may re­sult in un­nec­es­sary in­va­sive test­ing such as coro­nary an­giog­ra­phy and revas­cu­larization pro­ce­dures. The ul­ti­mate bal­ance of benefit, cost, and risks of such an ap­proach in asymp­tomat­ic pa­tients re­mains con­tro­ver­sial, par­tic­u­lar­ly in the mod­ern set­ting of ag­gres­sive ASCVD risk fac­tor con­trol.