PracticeUpdate: Diabetes

EDITOR’S PICKS 9

Natural History of Diabetic Coronary Atherosclerosis by QuantitativeMeasurement of Serial Coronary CTA JACC: Cardiovascular Imaging Take-home message • Patients with and without diabetes mellitus (DM) underwent serial coronary computed tomography angiography over 24 months to evaluate plaque progression (PP), changes in plaque features, and clinical predictors of PP in patients with DM. DM was a significant independent risk factor for PP. In patients with DM, other independent risk factors were male gender and mean plaque burden at baseline ≥75%. Patients with DM showed significantly greater changes in overall plaque volume and necrotic core volume than those without. In addition, patients with DM showed significantly greater frequency of spotty calcification, positive remodeling, and burden of low-attenuation plaque compared with patients without. • Compared with patients without DM, individuals with DM are at risk of greater PP particularly affecting adverse plaque. Abstract OBJECTIVES This study aimed to determine the rate and extent of plaque progression (PP), changes in plaque features, and clinical predictors of PP in patients with diabetes mellitus (DM). BACKGROUND The natural history of coronary PP in patients with DM is not well established. METHODS A total of 1,602 patients (age 61.3 ± 9.0 years; 60.3% men; median scan interval 3.8 years) who underwent serial coronary computed tomog- raphy angiography over a period of at least 24 months were enrolled and analyzed from the PARADIGM (Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging) trial. Study endpoints were changes in plaque features in diabetics with PP and risk fac- tors for PP by serial coronary computed tomography angiography between patients with and without DM. PP was defined if plaque volume at follow-up minus plaque volume at baseline was >0. RESULTS DM was an independent risk factor for PP (84.6%; 276 of 326 patients with PP) in multivariate analysis (odds ratio [OR]: 1.526; 95% con- fidence interval [CI]: 1.100 to 2.118; p = 0.011). Independent risk factors for PP in patients with DM were male sex (OR: 1.485; 95% CI: 1.003 to 2.199; p = 0.048) and mean plaque burden at baseline ≥75% (OR: 3.121; 95% CI: 1.701 to 5.725; p ≤ 0.001). After propensity matching, percent changes in overall plaque volume (30.3 ± 36.9% in patients without DM and 36.0 ± 29.7% in those with DM; p = 0.032) and necrotic core volume (-7.0 ± 35.8% in patients without DM and 21.5 ± 90.5% in those with DM; p = 0.007) were significantly greater in those with DM. The frequency of spotty calcification, positive remodeling, and burden of low-attenuation plaque were signifi- cantly greater in patients with DM. CONCLUSIONS People with DM experience greater PP, particularly significantly greater progression in adverse plaque, than those without DM. Male sex and mean plaque burden >75% at baseline were identified as independ- ent risk factors for PP. Natural History of Diabetic Coronary Atherosclerosis by Quantitative Meas- urement of Serial Coronary Computed Tomographic Angiography: Results of the PARADIGM Study (Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging). JACC Cardiovasc Imag- ing 2018 May 11;[EPub Ahead of Print], U Kim, JA Leipsic, SL Sellers, et al. www.practiceupdate.com/c/68414

" These findings remain in agreement with the recently published 2017 ACC/ AHA Clinical Practice Guideline on Hypertension and with the 2018 ADA Standards of Medical Care in diabetes… "

as the first occurrence of a ≥30% decline in eGFR to an eGFR<60 ml/ min per 1.73 m 2 , initiation of dialysis, or kidney transplant. The compos- ite cardiovascular event end point was defined as the first occurrence of hospitalization for acute myocardial infarction, acute coronary syn- drome, stroke, or congestive heart failure; coronary artery bypass grafting; or percutaneous coronary intervention, and it was only exam- ined in those free of cardiovascular disease at baseline. RESULTS Over a maximum of 5 years, there were 4707 significant kid- ney events, 1498 deaths, and 818 cardiovascular events. Compared with thiazide diuretics, hazard ratios for significant kidney events for β-blockers, calcium channel blockers, and loop diuretics were 0.81 (95% confidence interval, 0.74 to 0.89), 0.67 (95% confidence interval, 0.58 to 0.78), and 1.19 (95% confidence interval, 1.00 to 1.41), respectively. Compared with thiazide diuretics, hazard ratios of mor- tality for β-blockers, calcium channel blockers, and loop diuretics were 1.19 (95% confidence interval, 0.97 to 1.44), 0.73 (95% confidence interval, 0.52 to 1.03), and 1.67 (95% confidence interval, 1.31 to 2.13), respectively. Compared with thiazide diuretics, hazard ratios of cardi- ovascular events for β-blockers, calcium channel blockers, and loop diuretics compared with thiazide diuretics were 1.65 (95% confidence interval, 1.39 to 1.96), 1.05 (95% confidence interval, 0.80 to 1.39), and 1.55 (95% confidence interval, 1.05 to 2.27), respectively. CONCLUSIONS Compared with thiazide diuretics, calcium channel block- ers were associated with a lower risk of significant kidney events and a similar risk of cardiovascular events. Add-On Antihypertensive Medications to Angiotensin-Aldosterone System Blockers in Diabetes: A Comparative Effectiveness Study. Clin J Am Soc Nephrol 2018 May 07;13(5)727-734, EB Schroeder,

M Chonchol, SM Shetterly, et al. www.practiceupdate.com/c/68937

VOL. 2 • NO. 3 • 2018