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I pazienti con alto rischio cardiometabolico hanno lesioni coronariche minori ma prognosi uguale ai diabetici non in insulina

Ipertensione, obesità, ipertrigliceridemia, basso colesterolo HDL, disglicemia. In pratica gli stessi fattori per la definizione di sindrome metabolica. Tre di questi fattori se contemporaneamente presenti, come per la sindrome metabolica, identificano, secondo gli autori di questo studio, l'alto rischio cardiometabolico. La prevalenza di lesioni coronariche di qualsiasi gravità è risultata essere del 51% nei non diabetici con meno di tre fattori di rischio, del 60% nei non diabetici con più di tre fattori di rischio, del 71% nei diabetici che non richiedevano insulina per il controllo metabolico e del 80% in quelli in terapia insulinica. Al progressivo aumento della gravità e dell'estensione delle lesioni coronariche all'angio TAC, corrispondeva un progressivo peggioramento della prognosi con un'eccezione che riguardava i pazienti non diabetici ad alto rischio e quelli diabetici non in terapia insulinica che, a fronte di diversa gravità ed estensione di lesioni coronariche, hanno avuto un'incidenza di eventi cardiovascolari, dopo poco più di 3 anni di follow-up, sostanzialmente sovrapponibile. Prognosi peggiore per i diabetici in terapia insulinica che erano quelli che mostravano anche un peggiore quadro coronarico all'angio-TAC.

Cardiometabolic risk is associated with atherosclerotic burden and prognosis: results from the partners coronary computed tomography angiography registry

Hulten E, Bittencourt MS, O'Leary D, Shah R, Ghoshhajra B, Christman MP, Montana P, Steigner M, Truong QA, Nasir K, Rybicki F, Hainer J, Brady TJ, Di Carli MF, Hoffmann U, Abbara S, Blankstein R

Diabetes Care 2014;37:555-564

OBJECTIVE: Our purpose was to evaluate coronary artery disease (CAD) prevalence and prognosis according to cardiometabolic (CM) risk.
RESEARCH DESIGN AND METHODS: Registry of all patients without prior CAD referred for coronary computed tomography angiography (CCTA). Patients were stratified by groups of increasing CM risk factors (hypertension, low HDL, hypertriglyceridemia, obesity, and dysglycemia) as follows: patients without type 2 diabetes mellitus (T2DM) with fewer than three or with three or more CM risk factors, patients with T2DM not requiring insulin, or those with T2DM requiring insulin. Patients were followed for a primary end point of major adverse cardiovascular events (MACE) composed of unstable angina, late coronary revascularization, myocardial infarction (MI), and cardiovascular mortality.
RESULTS: Among 1,118 patients (mean age 57 ± 13 years) followed for a mean 3.1 years, there were 21 (1.9%) cardiovascular deaths and 13 (1.2%) MIs. There was a stepwise increase in the prevalence of obstructive CAD with increasing CM risk, from 15% in those without diabetes and fewer than three CM risk factors to as high as 46% in patients with T2DM requiring insulin (P < 0.001). Insulin exposure was associated with the highest adjusted hazard of MACE (hazard ratio 3.29 [95% CI 1.28-8.45], P = 0.01), whereas both T2DM without insulin (1.35, P = 0.3) and three or more CM risk factors without T2DM (1.48, P = 0.3) were associated with a similar rate of MACE.
CONCLUSIONS: Patients without diabetes who have multiple metabolic risk factors have a similar prognosis and burden of CAD as those with T2DM not requiring insulin. Among patients with diabetes, the need for insulin therapy is associated with greater burden of CAD as well as worse prognosis.

Diabetes Care 2014;37:555-564