RESUMEN
The prevalence of diabetes mellitus is fairly increasing, especially in the developing countries. Diabetes is a major cardiovascular risk factor; it often leads to severe cardiovascular complications, and coronary artery disease (CAD) is the main cause of death in diabetic patients. Silent myocardial ischemia (SMI) is more frequent in diabetic patients. The progress made in detection and treatment of CAD allows reconsidering the screening of SMI, in the hope that early CAD diagnosis leads to a more effective therapy and the decrease of cardiovascular complications and mortality. However, the benefit of systematic SMI screening remains discussed. Current guidelines recommend screening SMI in asymptomatic diabetic patients selected for high cardiovascular risk (i.e. with two or more other cardiovascular risk factors, or peripheral or carotid arterial disease, or proteinuria). ECG stress test can be recommended in first intention if maximal heart rate can be achieved. For patient with inconclusive ECG stress test, myocardial scintigraphy seems more accurate than stress echocardiography. Coronary angiogram should be performed in case of positive stress test. Further evaluations of systematic screening have to be conducted on broad randomized trial.
Asunto(s)
Enfermedad de la Arteria Coronaria/diagnóstico , Angiopatías Diabéticas/diagnóstico , Tamizaje Masivo/métodos , Isquemia Miocárdica/diagnóstico , Presión Sanguínea , Angiografía Coronaria , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Electrocardiografía , Prueba de Esfuerzo , Frecuencia Cardíaca , Humanos , Factores de Riesgo , Tomografía Computarizada de Emisión de Fotón ÚnicoRESUMEN
The prevalence of diabetes mellitus is fairly increasing, especially in the developing countries. Diabetes is a major cardiovascular risk factor; it often leads to severe cardiovascular complications, and coronary artery disease (CAD) is the main cause of death in diabetic patients. Silent myocardial ischemia (SMI) is more frequent in diabetic patients. The progress made in detection and treatment of CAD allows reconsidering the screening of SMI, in the hope that early CAD diagnosis leads to a more effective therapy and the decrease of cardiovascular complications and mortality. However, the benefit of systematic SMI screening remains discussed. Current guidelines recommend screening SMI in asymptomatic diabetic patients selected for high cardiovascular risk (i.e. with two or more other cardiovascular risk factors, or peripheral or carotid arterial disease, or proteinuria). ECG stress test can be recommended in first intention if maximal heart rate can be achieved. For patient with inconclusive ECG stress test, myocardial scintigraphy seems more accurate than stress echocardiography. Coronary angiogram should be performed in case of positive stress test. Further evaluations of systematic screening have to be conducted on broad randomized trial.
A prevalência do diabetes mellitus está crescendo de forma importante, em especial nos países em desenvolvimento. A isquemia miocárdica silenciosa (IMS) é mais freqüente em diabéticos. Ainda, o diabetes é um forte fator de risco cardiovascular, sendo que, com freqüência, leva a graves complicações cardiovasculares. A doença arterial coronariana (DAC) é a principal causa de morte em pacientes com diabetes. Os progressos alcançados na detecção e tratamento da DAC permitem considerar o rastreamento da IMS, na expectativa de que o diagnóstico precoce levaria a terapias mais efetivas e a redução das complicações cardiovasculares e da mortalidade. Entretanto, o benefício do rastreamento sistemático da IMS permanece discutível. Recomendações atuais sugerem o rastreamento em pacientes diabéticos assintomáticos selecionados por possuírem alto risco cardiovascular (ex. dois ou mais marcadores de risco, ou doença arterial periférica ou doença arterial das carótidas, ou proteinúria). O ECG de stress pode ser considerado como teste inicial se a freqüência cardíaca máxima for atingida. Nos pacientes com este teste inconclusivo, a cintilografia do miocárdio parece ter mais acurácia diagnóstica do que o ecocardiograma de stress. A angiografia coronariana deve ser indicada em casos com teste de stress positivo. Avaliações futuras do rastreamento sistemático devem ser conduzidas em estudos randomizados multicênctricos.