Mayo Clinic Proceedings Home

Impact of Stress Testing for Coronary Artery Disease Screening in Asymptomatic Patients With Diabetes Mellitus: A Community-Based Study in Olmsted County, Minnesota

Published:October 06, 2016DOI:



      To evaluate the impact of screening stress testing for coronary artery disease in asymptomatic patients with diabetes in a community-based population.

      Patients and Methods

      This observational study included 3146 patients from Olmsted County, Minnesota, with no history of coronary artery disease or cardiac symptoms in whom diabetes was newly diagnosed from January 1, 1992, through December 31, 2008. With combined all-cause mortality and myocardial infarction as the primary outcome, weighted Cox proportional hazards regression was performed with screening stress testing within 2 years of diabetes diagnosis as the time-dependent covariate. For descriptive analysis, participants were classified by their clinical experience during the first 2 years postdiagnosis as screened (asymptomatic, underwent stress test), unscreened (asymptomatic, no stress test), or symptomatic (experienced symptoms or event).


      Among the screened and unscreened participants, 54% (1358 of 2538) were men; the mean (SD) age at diabetes diagnosis was 55 years (13.8 years), and 97% (2442 of 2520) had type 2 diabetes. In event-free survival analysis, 292 patients comprised the screened cohort and 2246 patients comprised the unscreened cohort. Death or myocardial infarction occurred in 454 patients (32 patients in the screened cohort and 422 in the unscreened cohort [5-year rate, 1.9% and 5.3%, respectively]) during median (interquartile range) follow-up of 9.1 years (5.3-12.5 years). Screening stress testing was associated with improved event-free survival (hazard ratio, 0.61; P=.004), independent of cardiac risk factors. However, while stress test results were abnormal in 47 of the 292 screened patients (16%), only 6 (2%) underwent coronary revascularization.


      Although screening cardiac stress testing in asymptomatic patients with diabetes in this community-based population was associated with improvement in long-term event-free survival, this result does not appear to occur by coronary revascularization alone.

      Abbreviations and Acronyms:

      BP (blood pressure), CAD (coronary artery disease), DIAD (Detection of Ischemia in Asymptomatic Diabetics), ECG (electrocardiography), FRS (Framingham Risk Score), HR (hazard ratio), MI (myocardial infarction), REP (Rochester Epidemiology Project)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Centers for Disease Control and Prevention
        National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014.
        US Department of Health and Human Services, Atlanta, GA2014
        • Grundy S.M.
        • Benjamin I.J.
        • Burke G.L.
        • et al.
        Diabetes and cardiovascular disease: a statement for healthcare professionals from the American Heart Association.
        Circulation. 1999; 100 ([published correction appears in Circulation. 2000;101(13):1629-1631]): 1134-1146
        • Koistinen M.J.
        Prevalence of asymptomatic myocardial ischaemia in diabetic subjects.
        BMJ. 1990; 301: 92-95
        • American Diabetes Association
        Consensus development conference on the diagnosis of coronary heart disease in people with diabetes: 10-11 February 1998, Miami, Florida.
        Diabetes Care. 1998; 21: 1551-1559
        • Rydén L.
        • Grant P.J.
        • Anker S.D.
        • et al.
        ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD.
        Eur Heart J. 2013; 34 ([published correction appears in Eur Heart J. 2014;35(27):1824]): 3035-3087
        • American Diabetes Association
        Cardiovascular disease and risk management.
        Diabetes Care. 2016; 39: S60-S71
        • Young L.H.
        • Wackers F.J.
        • Chyun D.A.
        • et al.
        • DIAD Investigators
        Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study; a randomized controlled trial.
        JAMA. 2009; 301: 1547-1555
        • Sorlie P.
        • Wei G.S.
        Population-based cohort studies: still relevant?.
        J Am Coll Cardiol. 2011; 58: 2010-2013
        • Rocca W.A.
        • Yawn B.P.
        • St Sauver J.L.
        • Grossardt B.R.
        • Melton III, L.J.
        History of the Rochester Epidemiology Project: half a century of medical records linkage in a US population.
        Mayo Clin Proc. 2012; 87: 1202-1213
        • US Census Bureau
        2010 Census Redistricting Data (Public Law 94–171) Summary file—Technical Documentation.
        US Census Bureau, Washington, DC2011 (Tables P1, P2, and H1)
        • St Sauver J.L.
        • Grossardt B.R.
        • Leibson C.L.
        • Yawn B.P.
        • Melton III, L.J.
        • Rocca W.A.
        Generalizability of epidemiological findings and public health decisions: an illustration from the Rochester Epidemiology Project.
        Mayo Clin Proc. 2012; 87: 151-160
        • St Sauver J.L.
        • Grossardt B.R.
        • Yawn B.P.
        • et al.
        Data resource profile: the Rochester Epidemiology Project (REP) medical records-linkage system.
        Int J Epidemiol. 2012; 41: 1614-1624
        • St Sauver J.L.
        • Grossardt B.R.
        • Yawn B.P.
        • Melton III, L.J.
        • Rocca W.A.
        Use of a medical records linkage system to enumerate a dynamic population over time: the Rochester Epidemiology Project.
        Am J Epidemiol. 2011; 173: 1059-1068
        • Adams L.A.
        • Harmsen S.
        • St Sauver J.L.
        • et al.
        Nonalcoholic fatty liver disease increases risk of death among patients with diabetes: a community-based cohort study.
        Am J Gastroenterol. 2010; 105: 1567-1573
        • James P.A.
        • Oparil S.
        • Carter B.L.
        • et al.
        2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
        JAMA. 2014; 311 ([published correction appears in JAMA. 2014;311(17):1809]): 507-520
        • Wilson P.W.
        • D’Agostino R.B.
        • Levy D.
        • Belanger A.M.
        • Silbershatz H.
        • Kannel W.B.
        Prediction of coronary heart disease using risk factor categories.
        Circulation. 1998; 97: 1837-1847
        • Pellikka P.A.
        • Nagueh S.F.
        • Elhendy A.A.
        • Kuehl C.A.
        • Sawada S.G.
        American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography.
        J Am Soc Echocardiogr. 2007; 20: 1021-1041
        • Strauss H.W.
        • Miller D.D.
        • Wittry M.D.
        • et al.
        Procedure guideline for myocardial perfusion imaging.
        J Nucl Med. 1998; 39: 918-923
        • Gibbons R.J.
        • Balady G.J.
        • Bricker J.T.
        • et al.
        ACC/AHA 2002 guideline update for exercise testing: summary article; a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines).
        J Am Coll Cardiol. 2002; 40 ([published correction appears in J Am Coll Cardiol. 2006;48(8):1731]): 1531-1540
        • Anderson J.R.
        • Cain K.C.
        • Gelber R.D.
        Analysis of survival by tumor response.
        J Clin Oncol. 1983; 1: 710-719
        • Lièvre M.M.
        • Moulin P.
        • Thivolet C.
        • et al.
        • DYNAMIT Investigators
        Detection of silent myocardial ischemia in asymptomatic patients with diabetes: results of a randomized trial and meta-analysis assessing the effectiveness of systematic screening.
        Trials. 2011; 12: 23
        • Zellweger M.J.
        • Maraun M.
        • Osterhues H.H.
        • et al.
        Progression to overt or silent CAD in asymptomatic patients with diabetes mellitus at high coronary risk: main findings of the prospective multicenter BARDOT trial with a pilot randomized treatment substudy.
        J Am Coll Cardiol Img. 2014; 7: 1001-1010
        • Milan Study on Atherosclerosis and Diabetes (MiSAD) Group
        Prevalence of unrecognized silent myocardial ischemia and its association with atherosclerotic risk factors in noninsulin-dependent diabetes mellitus.
        Am J Cardiol. 1997; 79: 134-139
        • Rajagopalan N.
        • Miller T.D.
        • Hodge D.O.
        • Frye R.L.
        • Gibbons R.J.
        Identifying high-risk asymptomatic diabetic patients who are candidates for screening stress single-photon emission computed tomography imaging.
        J Am Coll Cardiol. 2005; 45: 43-49
        • Muhlestein J.B.
        • Lappé D.L.
        • Lima J.A.
        • et al.
        Effect of screening for coronary artery disease using CT angiography on mortality and cardiac events in high-risk patients with diabetes: the FACTOR-64 randomized clinical trial.
        JAMA. 2014; 312: 2234-2243
        • Davis T.M.
        • Coleman R.L.
        • Holman R.R.
        • UKPDS Group
        Prognostic significance of silent myocardial infarction in newly diagnosed type 2 diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS) 79.
        Circulation. 2013; 127: 980-987
        • Action to Control Cardiovascular Risk in Diabetes Study Group
        Effects of intensive glucose lowering in type 2 diabetes.
        N Engl J Med. 2008; 358: 2545-2559
        • Galper B.Z.
        • Moran A.
        • Coxson P.G.
        • et al.
        Using stress testing to guide primary prevention of coronary heart disease among intermediate-risk patients: a cost-effectiveness analysis.
        Circulation. 2012; 125: 260-270