ENFERMEDAD ARTERIAL CORONARIA

EN PACIENTES DIABÉTICOS
Dra. Isabel Lastra
R1 Medicina Interna
 Prevalencia
• Alta prevalencia de enfermedad arterial
coronaria
• Mayor extensión de isquemia miocárdica
• Infarto al miocardio
• Isquemia al miocardio silente.
 Diabetes como equivalente de CHD
• Análisis de 698.782 personas
• Riesgo de enfermerdad arterial coronaria de 2·00
(95% CI 1·83–2·19)
• Mujeres > Hombres (40–59 años)
• Mortalidad 11 vs 10% por enfermedades
vasculares.
• 2 veces más riesgo de enfermedades vasculares
independientemente de otros factores
convencionales.
Emerging Risk Factors Collaboration, Diabetes mellitus, fasting blood glucose concentration, and risk of vascular
disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010 Jun 26;375(9733):2215-22
Figure 1.
Hazard ratios (HRs) for vascular outcomes in people with versus those without diabetes at
baseline
Analyses were based on 530 083 participants. HRs were adjusted for age, smoking status, bodymass
index, and systolic blood pressure, and, where appropriate, stratified by sex and trial arm.
208 coronary heart disease outcomes that contributed to the grand total could not contribute to
the subtotals of coronary death or non-fatal myocardial infarction because there were fewer
than 11 cases of these coronary disease subtypes in some studies. *Includes both fatal and nonfatal
events.
Hazard ratios (HRs) for coronary heart disease and ischaemic stroke in people with versus those without diabetes at baseline,
by individual characteristics
HRs were adjusted as described in figure 1. BMI=body-mass index. *Bottom third=<23·8 kg/m 2 (mean 21·7 kg/m2); middle
third=23·8–<27 kg/m2 (mean 25·3 kg/m2); and top third=≥27 kg/m2 (mean 30·7 kg/m2). †Bottom third=<123 mm Hg (mean
113 mm Hg); middle third=123–<141 mm Hg (mean 132 mm Hg); and top third=≥141 mm Hg (mean 157 mm Hg
 Extensión de enfermedad coronaria

TI
Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus.
AU
Scognamiglio R, Negut C, Ramondo A, Tiengo A, Avogaro A
SO
J Am Coll Cardiol. 2006;47(1):65-71.
 
In type 2 diabetes mellitus (DM2) patients, coronary artery disease (CAD) generally is detected in an advanced stage, whereas an
asymptomatic stage is commonly missed. Abnormal myocardial perfusion during stress myocardial contrast echocardiography
(MCE) and significant CAD were similar, irrespective of risk factor (RF) profile in our patients, but coronary anatomy differed. An
"aggressive" diagnostic approach, requiring coronary angiography in asymptomatic DM2 patients with<or = 1 associated RF for
CAD and abnormal MCE, identified silent CAD, characterized by a more favorable angiographic anatomy. The criterion of>or = 2
RFs did not help to identify patients with a higher prevalence of CAD and is only related to a more severe coronary
atherosclerosis with unfavorable anatomy.OBJECTIVES: We sought to verify the effectiveness of current American Diabetes
Association screening guidelines in identifying asymptomatic patients with coronary artery disease (CAD) in type 2 diabetes
mellitus (DM2). BACKGROUND: In DM2 patients, CAD generally is detected in an advanced stage with an extensive atherosclerosis
and poor outcome, whereas CAD in an asymptomatic stage is commonly missed. METHODS: This study included 1,899
asymptomatic DM2 patients (age<or = 60 years). Of these, 1,121 had>or = 2 associated risk factors (RFs), group A, and the
remaining 778 had<or = 1 RF, group B, for CAD. All patients underwent dipyridamole myocardial contrast echocardiography
(MCE), and in those with myocardial perfusion defects, the anatomy of coronary vessels was analyzed by selective coronary
angiography. RESULTS: In the two study groups, the prevalence of abnormal MCE (59.4% vs. 60%, p = 0.96) and of a significant
CAD (64.6% vs. 65.5%, p = 0.92) was similar, irrespective of RF profile. But coronary anatomy differed: group B had a lower
prevalence of three-vessel disease (7.6% vs. 33.3%, p<0.001), of diffuse disease (18.0% vs. 54.9%, p<0.001), and of vessel
occlusion (3.8% vs. 31.2%, p<0.001), whereas one-vessel disease was more frequent (70.6% vs. 46.3%, p<0.001). Coronary
anatomy did not allow any revascularization procedure in 45% of group A patients. CONCLUSIONS: An "aggressive" diagnostic
approach, requiring coronary angiography in asymptomatic DM2 patients with<or =1 associated RF for CAD and abnormal MCE,
identified patients with a subclinical CAD characterized by a more favorable angiographic anatomy. The criterion of>or =2 RFs did
not help to identify asymptomatic patients with a higher prevalence of CAD and is only related to a more severe CAD with
unfavorable coronary anatomy.
 Infarto al miocardio
• 24
• TI
• Cardiovascular events in diabetic and nondiabetic adults with or without history of myocardial infarction.
• AU
• Lee CD, Folsom AR, Pankow JS, Brancati FL, Atherosclerosis Risk in Communities (ARIC) Study Investigators
• SO
• Circulation. 2004;109(7):855-60.
•  
• BACKGROUND: Whether diabetic patients without a history of myocardial infarction (MI) have the same risk of coronary heart disease (CHD) events as
nondiabetic patients with a history of MI remains controversial. We compared risks of CHD and stroke events and mortality from cardiovascular disease (CVD) in
diabetic and nondiabetic men and women with and without a history of MI. METHODS AND RESULTS: We followed a total of 13 790 African American and white
men and women ages 45 to 64 years who participated in the Atherosclerosis Risk in Communities study, beginning in 1987 to 1989. There were 634 fatal CHD or
nonfatal MI events, 312 fatal or nonfatal strokes, and 358 deaths from CVD during an average of 9 years of follow-up (125 998 person-years). After adjustment
for age, sex, race, Atherosclerosis Risk in Communities field center, and multiple baseline risk factors, patients who had a history of MI without diabetes at
baseline had 1.9 times the risk of fatal CHD or nonfatal MI (95% CI, 1.35 to 2.56; P<0.001) compared with diabetic patients without a prior history of MI. The
nondiabetic patients with MI also had 1.8 times the risk of CVD mortality compared with diabetic patients without MI (95% CI, 1.22 to 2.72; P=0.003). However,
stroke risk was similar between diabetic patients without MI and nondiabetic patients with MI (RR, 1.05; 95% CI, 0.61 to 1.79; P=0.87). We also observed that
nondiabetic patients with MI had a carotid artery wall thickness similar to diabetic patients without MI (P=0.77). CONCLUSIONS: Diabetic patients without MI
had lower risk of CHD events and mortality from CVD compared with nondiabetic patients with MI, but stroke risk was similar between these 2 groups.
• AD
• Department of Sports and Exercise Sciences, West Texas A&M University, Canyon, Tex, USA.
• PMID
• 14757692
• No diabetes and no MI — 3.9 percent
• Diabetes and no MI — 10.8 percent
• No diabetes and prior MI — 18.9 percent
• Diabetes and prior MI — 32.2 percent
 ISQUEMIA SILENTE E INFARTO

Desnervación autonómica del Alteración en la percepción de

corazón (regional) angina

Inestabilidad eléctrica miocárdica

Arritmias
Enfermedad arterial coronaria asintomática

• Asociación con calcificación de arterias

coronarias
• Isquemia silente e infarto

Desnervación autonómica del corazón

inestabilidad eléctrica miocárdica