A Novel And Practical Screening Tool For The Detection Of Silent Myocardial Infarction In Patients With Type 2 Diabetes
Silent myocardial infarction (MI) is a prevalent finding in patients with type 2 diabetes and is associated with significant mortality and morbidity. Late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR) is the most validated technique for detection of silent MI, but is time-consuming, costly, and requires administration of intravenous contrast. We therefore planned to develop a simple and low-cost population screening tool to identify those at highest risk of silent MI validated against the CMR reference standard. Continue reading >>
- Identification of novel biomarkers to monitor β-cell function and enable early detection of type 2 diabetes risk
- A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes
- A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes
Silent Heart Attacks And Type 2 Diabetes
With commentary by Elsayed Z. Soliman, M.D., MSc., M.S., study senior author and director of the epidemiological cardiology research center at Wake Forest Baptist Medical Center, Winston-Salem, North Carolina. Not all heart attacks announce themselves with Hollywood-style crushing chest pain and a drenching, cold sweat. When researchers from Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, checked the hearts and medical records of 9,498 people over nine years, they found1 nearly equal numbers of untreated, silent heart attacks and recognized heart attacks that had received medical attention. A silent heart attack may be missed because the symptoms are mild or seem like another, less-urgent health issue – such as indigestion, heartburn, the flu, fatigue or an ache-y muscle – notes Elsayed Z. Soliman, M.D., MSc., M.S., study senior author and director of the epidemiological cardiology research center at Wake Forest Baptist Medical Center, Winston-Salem, North Carolina. “People may also decide not to go to the hospital if they’re not sure it’s a heart attack, or if the hospital is far away, they don’t have health insurance or are concerned about the cost of care,” Dr. Soliman told EndocrineWeb.com. But in the study, published May 16 in the journal Circulation, that proved deadly. People who’d had silent heart attacks were three times more likely than those who hadn’t had a heart attack at all to die. Typically, people who’ve had a silent heart attack miss out on emergency care that can save heart muscle during a heart attack such as fast treatment with procedures that open blocked arteries in the heart. They may also miss out on stepped-up attention to blood pressure, cholesterol, diet, exercise and stress afterwards that lower risk Continue reading >>
Silent Heart Disease In Diabetes: "why Don't I Feel It?"
Whenever something bad happens there is an irrational thought process that causes each of us to try to assess “blame”. This is no different for doctors than it is for other people. I can’t think of anything much stranger than the discussion I hear from physicians after a young patient comes in with a heart attack. You can almost see the gears turning in each doctor’s head. The first thought is that the patient has a family history, high blood pressure, uses cocaine or alcohol or tobacco, has high cholesterol, is diabetic, has congenital heart disease or rheumatic fever or any other problem that differentiates him/her from the doctor. After all, the doctor doesn’t want to feel that this could happen to him/her. The next thought is that the patient must have been doing something to cause this catastrophe (not like the doctor), and certainly the patient should have known that something was wrong. These are common thoughts that people have (doctors included). We don’t want to think that heart attacks can just sneak up and hit us. Unfortunately, not every heart attack is preceded or accompanied by symptoms. This is often not because the patient is ignoring the problem (though sometimes people do this or hide their symptoms from everyone). Approximately 15% of heart attacks are “silent”, meaning that they are discovered during a time when the patient has an electrocardiogram or echocardiogram for another reason. In diabetics, the percentage of heart attacks that are “silent” is somewhat higher (25%). It is thought that this is because there is a problem with the nerves that carry the symptoms of pain to the brain due to the diabetes. Why should we be surprised that a blood vessel can get blocked without a warning? Strokes often happen the same way. No warn Continue reading >>
Silent Heart Attack: What Are The Risks?
A silent heart attack is a heart attack that has few, if any, symptoms. You may have never had any symptoms to warn you that you've developed a heart problem, such as chest pain or shortness of breath. Some people later recall their silent heart attack was mistaken for indigestion, nausea, muscle pain or a bad case of the flu. The risk factors for a silent heart attack are the same as those for a heart attack with symptoms. The risk factors include: Smoking or chewing tobacco Family history of heart disease Age High cholesterol High blood pressure Diabetes Lack of exercise Being overweight Having a silent heart attack puts you at a greater risk of having another heart attack, which could be fatal. Having another heart attack also increases your risk of complications, such as heart failure. There are no tests to determine your potential for having a silent heart attack, but if you have the risk factors, they should be evaluated by your doctor and treated to reduce your likelihood for having a silent heart attack. The only way to tell if you've had a silent heart attack is to have imaging tests, such as an electrocardiogram, echocardiogram or others. These tests can reveal changes that signal you've had a heart attack. If you wonder if you've had a silent heart attack, talk to your doctor. A review of your symptoms, health history and a physical exam can help your doctor decide if more tests are necessary. Continue reading >>
Silent Myocardial Ischemia In Diabetic And Nondiabetic Patients With Coronary Artery Disease
Abstract Background: Patients with diabetes mellitus are at increased risk for CAD; silent ischemia is reported to be frequent in diabetic populations. The aim of the present study was to evaluate the prevalence of silent ischemia in diabetic and nondiabetic patients with assessed CAD. Methods and results: We recruited a total of 618 patients with CAD: 309 were consecutive diabetic patients and 309 were age- and gender-matched nondiabetic patients. Myocardial ischemia was evaluated both during daily life and during exercise testing. Angina pectoris during daily life was more frequent in diabetic than in nondiabetic patients (80% vs. 74%, P<0.05). The anginal pain intensity either during daily life or acute myocardial infarction (MI), the prevalence of a previous MI, the extent of CAD and ergometric parameters were similar in diabetics and nondiabetics. Silent ischemia during exercise was documented in 179 (58%) diabetics and in 197 (64%) nondiabetics (nonsignificant, ns). Both diabetics and nondiabetics with silent exertional myocardial ischemia differed from symptomatic subjects in higher heart rate values (P<0.01), systolic blood pressure (P<0.01), rate–pressure product (P<0.001), work load (P<0.01) and maximum ST-segment depression at peak exercise (P<0.05). Conclusions: The incidence of silent myocardial ischemia during exercise was similar in diabetic and nondiabetic CAD patients. Surprisingly, diabetics showed a higher prevalence of angina pectoris during daily activity than nondiabetics. A significant association between the presence of symptoms during daily life and exercise was observed in both groups. Our results may contribute to the planning of the clinical management of diabetic CAD patients and confirm the individual attitude to pain of CAD patients inde Continue reading >>
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Silent Myocardial Infarctions More Common Than Previously Assumed
Image: PD 1. The prevalence of silent myocardial infarction (MI) in patients referred for coronary artery disease (CAD) evaluation is higher than previously thought, approaching one-quarter of all patients in this study. 2. Silent MI is 50% more common among patients with diabetes mellitus. Evidence Rating Level: 2 (Good) Study Rundown: Silent myocardial infarctions (MIs) lack unequivocal objective signs of myocardial infarction and have minimal, atypical, or no symptoms at all. Most such MIs are diagnosed with screening ECGs, though previous studies have demonstrated the low sensitivity of this method compared to myocardial perfusion single photon emission computed tomography (MPS). This study confirms that MPS improves the diagnostic capability of ECGs, as many patients with substantial infarctions lacked characteristic Q waves on ECG. It also suggests that silent MIs are more common than previously recognized, especially among diabetics. Nearly one quarter of enrolled patients had experienced a silent MI that had gone unrecognized. However, the study does not assess the prognosis of silent MIs; as such, the authors’ argument in favor of increased imaging modalities for detection and increased secondary prevention therapies cannot be backed by claims of cost-effectiveness. Future studies are required to determine optimal screening and prevention for individuals determined to be at risk for silent MIs. In-Depth [prospective cohort study]: This study analyzes silent myocardial infarction (MI) among two cohorts of patients without a prior history of MI who were referred for stress testing. Study participants underwent stress testing (exercise, pharmacological, or combined) and myocardial perfusion single photon emission computed tomography (MPS). Silent MI was defined Continue reading >>
Prevalence, Incidence, Predictive Factors And Prognosis Of Silent Myocardial Infarction: A Review Of The Literature
Summary The prevalence, incidence, risk factors and prognosis of silent myocardial infarction are less well known than those of silent myocardial ischaemia. The aims of this article are to evaluate the prevalence and incidence of silent myocardial infarction in subjects with or without a history of cardiovascular disease and in diabetic patients, and to identify potential risk factors and estimate prognosis through a review of the literature. A Medline search identified studies that provided data on the prevalence, incidence, potential risk factors and/or prognosis of silent myocardial infarction, among cohorts from the general population and large clinical studies of at-risk patients (with hypertension or a history of cardiovascular disease or diabetes). The search identified 15 studies in subjects from the general population, five in hypertensive patients, six in patients with a history of cardiovascular disease, and 10 in diabetic patients. The prevalence and incidence of silent myocardial infarction appear highly variable depending on the population studied, the patients’ ages, and the method used to detect silent myocardial infarction. In the general population, the prevalence of silent myocardial infarction increased markedly with increasing age (up to > 5% in elderly subjects). Hypertension causes only a moderate increase in prevalence, whereas underlying cardiovascular diseases and diabetes are associated with marked increases in prevalence. The incidence of silent myocardial infarction changes in the same way. The main predictive factors of silent myocardial infarction are hypertension, history of cardiovascular diseases and diabetes duration. Silent myocardial infarction is associated with as poor a prognosis as clinical myocardial infarction. The frequency Continue reading >>
A Silent Myocardial Infarction In The Diabetes Outpatient Clinic: Case Report And Review Of The Literature
Background Chest pain is a frightening symptom that typically alerts both the patient and the physician to the likelihood of underlying coronary artery disease. Absence of chest pain despite significant myocardial ischaemia is an important clinical entity. Such silent myocardial ischaemia (SMI), defined as objective evidence of myocardial ischaemia in the absence of symptoms, has important clinical implications for the patient with coronary artery disease. We present a dramatic case of SMI in a patient with diabetes, describe the aetiology of the condition and discuss the implications of silent ischaemia for the patient and for the physician caring for patients with diabetes. Case presentation A 62-year-old man attended the diabetes outpatient clinic for his annual review visit. He had been diagnosed with type 2 diabetes mellitus 6 years earlier. His diabetes was complicated by diabetic nephropathy, background diabetic retinopathy and peripheral neuropathy manifested by reduced vibration sense in both feet. He also suffered from hypertension and dyslipidaemia. His medications at the time of review included an angiotensin converting enzyme inhibitor, an α-blocker, a statin, metformin and aspirin. He was symptomatically well. Physical examination revealed a blood pressure of 155/83 mmHg, reduced vibration sense in his feet and palpable peripheral pulses. Laboratory tests revealed a HbA1c of 6.1%, lipid profile within goal range with total cholesterol 3.4 mmol/l, triglyceride 1.10 mmol/l, HDL 1.64 mmol/l and LDL 1.29 mmol/l. Serum creatinine was elevated at 120 mmol/l (58–110) and 24-h urinary protein 1.13 g. After his physician review was complete, an electrocardiogram (ECG) was performed as part of his routine annual assessment (Fig. 1). The patient was recalled to th Continue reading >>
Review Article Acute Myocardial Infarction In The Diabetic Patient: Pathophysiology, Clinical Course And Prognosis
Abstract Although there have been significant advances in the care of many of the extrapancreatic manifestations of diabetes, acute myocardial infarction continues to be a major cause of morbidity and mortality in diabetic patients. Factors unique to diabetes increase atherosclerotic plaque formation and thrombosis, thereby contributing to myocardial infarction. Autonomic neuropathy may predispose to infarction and result in atypical presenting symptoms in the diabetic patient, making diagnosis difficult and delaying treatment. The clinical course of myocardial infarction is frequently complicated and carries a higher mortality rate in the diabetic than in the nondiabelic patient. Although the course and pathophysiology of myocardial infarction differ to some degree in diabetic patients from those in patients without diabetes, much more remains to be known to formulate more effective treatment strategies in this high risk subgroup. Continue reading >>
Silent Myocardial Infarction
We are all taught that myocardial ischemia can present in many ways. The classic retrosternal chest pain, radiating to the neck and left arm is a pattern that is universally recognized amongst the public, but is not the only way a heart attack may manifest. In 1912, Herrick published an article describing the "clinical features of obstruction of the coronary arteries" in JAMA. There, he describes the entity of unrecognized myocardial infarction. His title still suggests that the pathophysiology in ischemia is the same in patients with silent MI, where poor perfusion to the cardiomyocytes leads to tissue hypoxia and infarction. The difference must be in how this abnormality is perceived and acted upon by patients. Autonomic neuropathy of afferent nerves has been a proposed mechanism, especially in diabetic patients. In 1977, a study looking at 5 patients with silent myocardial infarction and diabetes, and found pathologic changes in the autonomic nerves supplying the myocardium. These changes were consistent with diabetic neuropathy. These changes were not seen in diabetics and non-diabetics in patients with painful ACL presentations. "Gating" phenomenon has been described as another potential mechanism, where muting of afferent pain signals in the dorsal horns by additional sensory input (ex. dypnea) may overwhelm pain input and dampen down the pain perception. Additional factors have focused on supratentorial interpretation of pain, which can be influenced by other medical conditions such as depression. There was a theory that endorphins may play a role in suppressing pain in these patients, however studies involving the administration of naloxone in the setting of silent ischemia in exercise testing had no influence. Silent MI is likely an under-recognized condition. Continue reading >>
How Diabetes Can Mask The Symptoms Of A Heart Attack
Weird, whispering symptoms are easy to overlook; how to prevent and recognize this risk for people with diabetes. In a new study of more than 9,000 people, silent heart attacks—with warning signs so quiet or so unusual that people didn’t seek medical help—were nearly as common as classic heart attacks with well-known symptoms like crushing chest pain. And they were almost as lethal in the long run, tripling the odds of dying during the 9-year study compared to people who didn’t have a heart attack of any kind. It’s a wake-up call for anyone at risk for heart disease, but heart experts say people with type 1 and type 2 diabetes should pay particular attention. “People with diabetes are at higher risk for silent heart attacks for several reasons,” says Om P. Ganda, M.D., medical director of the Lipid Clinic at the Joslin Diabetes Center in Boston and an associate clinical professor of medicine at Harvard Medical School. “High blood sugar can lead to autonomic nerve damage that reduces the ability to feel pain, including heart-attack pain. Your only symptom might be shortness of breath. And people with diabetes are already at two to three time’s higher risk for heart disease than people without diabetes, which also increases the chances for a silent heart attack.” In a 2013 British study of 5,102 people with type 2, heart tests showed that 16%— about one in six—had likely had silent heart attacks. People with type 1 diabetes may also be at higher-than-average risk, Dr. Ganda says, due to nerve damage and overall heart-disease risk. Lead researcher Elsayed Z. Soliman, M.D., MSc., M.S., director of the epidemiological cardiology research center at Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, says silent heart attacks are dangerou Continue reading >>
Silent Myocardial Infarction: The Risk Beyond The First Admission
Most patients with myocardial infarction (MI) present with severe clinical symptoms such as angina pectoris. If the patient has no symptoms or atypical symptoms, the MI may be categorised as ‘silent’. In some (but not all) cases, silent MI may be later identified and referred to as ‘unrecognised MI’. Unrecognised MI is a common and clinically significant event. Data from several epidemiological studies that defined previous MI by the presence of abnormal Q waves on an electrocardiogram (ECG), suggest that 20– 40% of all MIs are unrecognised.1 An earlier publication of the Rotterdam Study reported an even higher proportion of 53% unrecognised MIs in older women.2 Importantly, an unrecognised Q-wave MI has significant clinical implications and carries a prognosis that is as poor as that for recognised MIs.3 4 In the Framingham Study, for example, 58% of men and 48% of women had died within 10 years after detection of unrecognised Q-wave MI: a rate similar to that seen in subjects with recognised MIs.3 In a more recent analysis of elderly subjects from the Cardiovascular Health Study, 7-year mortality was similar in those with clinically unrecognised and those with recognised MI (21% vs 25%, respectively).5 Most epidemiological studies investigating the relevance of ECG-based unrecognised MI have focused on mortality as outcome variable, with insufficient study of cardiovascular morbidity. Particularly, development of heart failure (HF) is an important predictor of long-term outcome after MI, and should therefore receive special attention in such studies.6 7 Even today, with enhanced treatment options for HF, this condition is still associated with severely reduced life expectancy, higher rates of hospitalisation and, not least, with significant reduction in qual Continue reading >>
Silent Myocardial Ischemia: Epidemiology, Pathophysiology, And Diagnosis
INTRODUCTION Angina pectoris, the term used for symptoms thought to be attributable to myocardial ischemia, typically manifests as chest discomfort, although other associated symptoms with ischemia may be present (eg, exertional shortness of breath, nausea, diaphoresis, fatigue). While angina has long been considered the cardinal symptom of myocardial ischemia and coronary heart disease, "silent" (asymptomatic) myocardial ischemia is the most common manifestation of coronary heart disease (CHD), accounting for more than 75 percent of ischemic episodes during daily life as assessed by electrocardiographic (ECG) monitoring [1]. (See "Angina pectoris: Chest pain caused by myocardial ischemia".) The epidemiology, pathophysiology, and diagnosis of silent myocardial ischemia will be reviewed here. Issues related to treatment and prognosis of silent myocardial ischemia are discussed separately. (See "Silent myocardial ischemia: Prognosis and therapy".) DEFINITION Silent myocardial ischemia is defined as the presence of objective evidence of myocardial ischemia in the absence of chest discomfort or another anginal equivalent symptom (eg, dyspnea, nausea, diaphoresis, etc). Objective evidence of silent myocardial ischemia may be obtained in several ways: ST segment changes consistent with ischemia seen during exercise treadmill testing or ambulatory monitoring. (See "Exercise ECG testing: Performing the test and interpreting the ECG results", section on 'ST segment depression'.) Reversible myocardial perfusion defects noted during radionuclide myocardial perfusion imaging. (See "Stress testing for the diagnosis of obstructive coronary heart disease", section on 'Radionuclide myocardial perfusion imaging'.) Continue reading >>
Incidence And Predictors Of Silent Myocardial Infarction In Type 2 Diabetes And The Effect Of Fenofibrate: An Analysis From The Fenofibrate Intervention And Event Lowering In Diabetes (field) Study
To determine the incidence and predictors of, and effects of fenofibrate on silent myocardial infarction (MI) in a large contemporary cohort of patients with type 2 diabetes in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study. Routine electrocardiograms taken throughout the study were assessed by Minnesota-code criteria for the presence of new Q-waves without clinical presentation and analysed with blinding to treatment allocation and clinical outcome. Of all MIs, 36.8% were silent. Being male, older age, longer diabetes duration, prior cardiovascular disease (CVD), neuropathy, higher HbA1c, albuminuria, high serum creatinine, and insulin use all significantly predicted risk of clinical or silent MI. Fenofibrate reduced MI (clinical or silent) by 19% [hazard ratio (HR) 0.81, 95% confidence interval (CI) 0.69–0.94; P = 0.006], non-fatal clinical MI by 24% (P = 0.01), and silent MI by 16% (P = 0.16). Among those having silent MI, fenofibrate reduced subsequent clinical CVD events by 78% (HR 0.22, 95% CI 0.08–0.65; P = 0.003). Silent and clinical MI have similar risk factors and increase the risk of future CVD events. Fenofibrate reduces the risk of a first MI and substantially reduces the risk of further clinical CVD events after silent MI, supporting its use in type 2 diabetes. Most patients with a myocardial infarction (MI) have significant symptoms and present to hospital for treatment. Some, however, have an asymptomatic MI that is identified later when an electrocardiogram (ECG) shows the presence of Q waves. The reported proportion of silent MIs ranges from 22 to 40%.1 Although patients with diabetes are at greater risk of MI, the proportion of silent MIs may be similar to that in the general population.2 One community-based observationa Continue reading >>
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Type 2 Diabetes: Silent Heart Problems
Aug. 6, 2004 -- It's known as silent ischemia: No chest pain; in fact there are no symptoms at all before a heart attack. For people with type 2 diabetes, this is a common condition -- one that doctors should test for, new research shows. Heart disease is the leading cause of death among people with diabetes. Yet, unlike other people, these patients have few symptoms until the advanced stages -- until their first heart attack, writes researcher Frans J. Wackers, MD, a professor of cardiovascular medicine with Yale University School of Medicine in New Haven, Conn. Wackers' paper appears in the current issue of Diabetes Care. People with diabetes who are at high risk for heart disease -- men who are smokers or have high blood pressure for example -- should get a treadmill stress test for heart disease, he says. According to the American Diabetes Association (ADA) guidelines, doctors should perform stress tests to check for coronary artery disease in people with diabetes who have two or more risks factors. Doctors have had difficulty detecting early-stage heart disease in diabetes patients because there is nerve damage throughout the body. Therefore, chest pain -- which is the heart's signal that it's not getting sufficient blood and oxygen -- is dampened considerably. This is the first study to examine how common asymptomatic heart disease is in people with type 2 diabetes and how effective the screening guideline set by the ADA is. Wacker's study involved more than 1,000 volunteers in 14 centers throughout the U.S. and Canada -- all about 60 years old, with type 2 diabetes, and with no known or suspected heart disease. Some had a stress test (like a treadmill test) to determine how well the heart can handle exercise. In this case, the test determines whether people with Continue reading >>
