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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 20  |  Issue : 1  |  Page : 46-53

Value of multislice computed tomography-coronary angiography in predicting coronary artery diseases in type-2 diabetic patients in the chest pain unit


1 Department of Cardiology, Military Hospital, Mostafa Kamel, Alexandria, Egypt
2 Department of Cardiology, Al-Azhar University, Cairo, Egypt
3 Department of Internal Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission12-Apr-2021
Date of Decision17-May-2021
Date of Acceptance21-May-2021
Date of Web Publication4-Mar-2022

Correspondence Address:
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/azmj.azmj_47_21

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  Abstract 


Background and aim Diabetes mellitus is a metabolic disorder affecting a wide range of the population all over the world. Microvascular and macrovascular complications are very common in diabetic patients with high incidence of affection of the coronary arteries. Rapid and efficient management in cases (especially diabetics) complaining of chest pain at the emergency department is a matter of great importance to decrease the incidence of subsequent complications. Our aim was to predict coronary artery diseases in type-2 diabetic patients with typical chest pain with normal initial cardiac investigations at the emergency room by using computed tomography (CT) coronary angiography.
Patients and methods A total number of 100 patients were included in this study and classified into two groups: 80 patients with diabetes mellitus (group A) and 20 nondiabetic patients (group B) presented with chest pain. Complete history was taken from the cases with performing of complete physical examination, and routine laboratory and radiological investigations. Additionally, echocardiography and multislice CT-coronary angiography (coronary computed tomography angiography) were done for all cases. Also, calcium score was calculated.
Results CT angiography revealed affection in 19 (23.8%) cases of the cases in group A with no affected cases in group B with a statistically significant difference between the two groups. There was a high statistically significant agreement between the findings of the CT angiography and coronary angiography results (P<0.001). CT angiography had sensitivity of 70.37%, specificity of 100%, positive predictive value 100%, negative predictive value 86.89%, and accuracy of 90%.
Conclusion An early coronary computed tomography angiography strategy has revealed high sensitivity in prediction of coronary artery disease affection as compared with ordinary coronary angiography in cases presented with chest pain to emergency department.

Keywords: coronary computed tomography angiography, coronary artery disease, diabetes mellitus


How to cite this article:
Habour RM, Shawki I, Faragallah I, Al-Adl H. Value of multislice computed tomography-coronary angiography in predicting coronary artery diseases in type-2 diabetic patients in the chest pain unit. Al-Azhar Assiut Med J 2022;20:46-53

How to cite this URL:
Habour RM, Shawki I, Faragallah I, Al-Adl H. Value of multislice computed tomography-coronary angiography in predicting coronary artery diseases in type-2 diabetic patients in the chest pain unit. Al-Azhar Assiut Med J [serial online] 2022 [cited 2022 Jun 29];20:46-53. Available from: http://www.azmj.eg.net/text.asp?2022/20/1/46/339075




  Introduction Top


Diabetes mellitus (DM) represents a great burden to the health system all over the world [1]. A global increase in the prevalence of DM was reported, especially in the developing countries, mostly due to modernization of life and unhealthy dietary patterns [2].

DM is associated with a great risk for developing early microvascular complications (neuropathy, retinopathy, and nephropathy) and late macrovascular complications [peripheral arterial disease, coronary artery disease (CAD), and cerebrovascular accident]. The macrocomplications are usually due to arterial atherosclerosis and are responsible for serious and sometimes fatal consequences [3].

Presentation with acute, potentially life-threatening chest pain is common in the emergency department and requires both efficient and fast management in order to decrease the subsequent complications and mortality. For these reasons, it is mandatory to provide rapid, accurate, and cost-effective evaluation methods for chest pain in the emergency department [4]

Identification of asymptomatic diabetic patients with high risk for developing serious cardiovascular events is usually very difficult. Recently, it is not recommended to depend on the routine exercise-stress testing and myocardial perfusion imaging for detection of reverse cardiac outcomes in diabetic patients in emergency situations and are associated with poor outcomes [5],[6].

The use of computed tomography (CT) in assessment of coronary arteries has been associated with certain difficulties due to the small diameter of the arteries and their adjacent location adjacent to the moving heart [7].

Multislice computed tomography-coronary angiography (MSCT-CA) is a new and efficient diagnostic modality to exclude CAD, especially in patients with an intermediate likelihood of CAD or when testing for ischemia is equivocal [8].

Despite this high degree of accuracy of coronary computed tomography angiography (CCTA) in diagnosis of symptomatic low–intermediate patients [9],[10], there is a debate about its role in diagnosing asymptomatic and diabetic patients [11],[12].

The aim of this study was to predict CADs in type-2 diabetic patients with typical chest pain with normal initial cardiac investigations at the emergency room by using CT-coronary angiography.


  Patients and methods Top


The study is conducted in accordance with Helsinki standards 2013. It is approved by the ethics committee of Mustafa Kamel Military Hospital and an informed consent was obtained from each participant. This is a cross-section comparative case–control study that was conducted at Computed Tomography Unit in Mustafa Kamel Military Hospital, Cairo, Egypt. A total of 100 patients were included and distributed into two groups: group A that included 80 patients with type-2 DM and group B that included 20 nondiabetic patients as a control group. We included cases with age more than or equal to 35 years who were presented with consistent chest pain who did not show evidence of acute ischemia on initial ECG and required admission or objective testing to exclude acute coronary syndrome (ACS).

The cases with the following criteria were excluded: patients with noncardiac chest pain, patients with congenital heart diseases, patients with heart failure, patients with ST-elevation myocardial infarction or non-ST-elevation myocardial infarction or resting segmental wall motion abnormalities detected by transthoracic echocardiography, and finally patients with CT-coronary angiography.

Before participating in the study, all patients were informed about the procedures, aim, and drawbacks of each intervention. Full and detailed history taking, general examination, and local examination were conducted for all the cases. Routine laboratory investigations (including blood sugar, glycosylated hemoglobin, and cardiac enzymes).

We also performed 12-lead ECG for every case with particular stress on rate, rhythm, and ischemic changes. Transthoracic two-dimensional echocardiography was ordered to assess the ejection fraction and wall motion abnormalities. Echocardiography was performed using Hewlett Packard HP Sonos 5500 and Philips envisor (Munich, Germany) echo set using a 4-MHz transducer.

Patients with normal 12-lead resting ECG, negative troponin without segmental wall motion abnormalities, and normal renal profile were sent to do CT-coronary angiography.

For CCTA, all examinations were carried out utilizing Toshiba Multislice Aquilion 320 system (Tokyo, Japan). Initially, a prospective nonenhanced coronary calcium scan was carried out, followed by CCTA. If the heart rate was more than or equal to 70 beats/min, extra oral ivabradine (7.5 mg two times per day, 3 days before the examination) was commenced.

We defined calcium score as a dense area located in the coronary artery that exceeds the threshold of 130 Hounsfield units.

Statistical analysis of data

Data analysis was performed by Statistical Package for the Social Sciences (SPSS 24.0, IBM/SPSS Inc., Chicago, Illinois, USA) software. Categorical data were expressed as frequencies and percentages (%), while in the quantitative data, we used mean and SD (for normally distributed data) and median and interquartile range (IQR) (for abnormally distributed data).

To compare two groups with categorical variables, χ2 test or Fisher’s exact test were used. To compare two groups with normally distributed quantitative variables, independent samples t test was used and Mann–Whitney U test was used if the data were abnormally distributed. P values less than 0.05 are considered significant. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and diagnostic accuracy were estimated to reflect the diagnostic ability of a test.


  Results Top


[Table 1] reveals no statistically significant difference in the mean age between the two groups (P=0.927). Males represent the majority of the cases in the two groups (57.5 and 70%) in group A and group B, respectively, with no statistically significant difference. There was a statistically significant difference in the risk factors between the cases in the two study groups with higher incidence of associated risk factors in group A (P=0.007).
Table 1 Demographic data and risk factors in the study groups

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There was no statistically significant difference in the associated chronic disease between the cases in the two study groups. Hypertension was detected in 45% of the cases in the two groups. Dyslipidemia was detected in 27.5 and 25% in group A and group B, respectively. Smoking was detected in 40 and 55% in group A and group B, respectively. Positive family history was detected in 17.5 and 35% in group A and group B, respectively.

[Table 2] shows that there was no statistically significant difference in the mean systolic blood pressure, diastolic blood pressure, and heart rate between the cases in the two study groups. Nonspecific ECG changes were detected in 22.5 and 40% in group A and group B, respectively. There was no statistically significant difference between the two groups (P=0.111).
Table 2 Comparison between the two studied groups according to vital signs, clinical presentation, and ECG changes

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Cardiac chest pain was present in 33.8 and 25% of the cases in the diabetic and nondiabetic groups, respectively. There was no statistically significant difference between the two groups (P=0.453).

Calcium score more than 0 was present in 58.8 and 55% in group A and group B, respectively. There was no statistically significant difference between the two groups (P=0.761). Also, there was no statistically significant difference in the calcium score between the cases in the two study groups (P=0.694).

As shown in [Table 3], according to coronary angioartery study, coronary obstruction was detected in 27 (33.8%) cases and five (25%) cases in group A and group B, respectively. There was no statistically significant difference between the two groups (P=0.453). In group A, the site of obstruction was left anterior descending in 24 cases, left circumflex artery in one case, and D1 in two cases, while in group B, the site of obstruction was left anterior descending in four cases and right circumflex artery in one case. According to the segment of affection, in group A, mid-segment was affected in seven (25.9%) cases and proximal segment in 20 (74.1%) cases, while in group B, the proximal segment was affected in all of the five cases (100%). The median CT angio-obstruction score in group A was 55 with range between 20 and 99, while in group B was 70 with range between 30 and 95.
Table 3 Comparison between the two studied groups according to coronary angioartery

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As shown in [Table 4], CT angiography revealed affection in 19 (23.8%) cases of the cases in group A with no affected cases in group B with statistically significant difference between the two groups. According to the segment of affection, in group A, mid-segment was affected in six (31.6%) cases and proximal segment in 13 (68.4%) cases. The median CT angio-obstruction score was 55 with range between 20 and 99 ([Table 5]).
Table 4 Comparison between the two studied groups according to computed tomography angioartery

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Table 5 Agreement (sensitivity, specificity, and accuracy) for computed tomography angioartery group A (N=80)

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There was a high statistically significant agreement between the findings of the CT angiography and coronary angiography results (P<0.001). CT angiography had sensitivity of 70.37%, specificity of 100%, PPV 100%, NPV 86.89%, and accuracy of 90%.


  Discussion Top


This study was conducted to predict CADs in type-2 diabetic patients with typical chest pain with normal initial cardiac investigations at the emergency room by using CT-coronary angiography.

This study was conducted at Cardiology Department, Mustafa Kamel Military Hospital. The total number of 100 patients were included in this study and classified into two groups: 80 patients with DM (group A) and 20 nondiabetic patients (group B).

In our study, the mean age of the included cases was 56.57 and 50.54 years in group B and group A, respectively (P=0.001).

Similar results were shown by Akalu and Birhan [13] where the mean age of the cases included in their study was 61.2±7.3 years. One hundred seventy-two (61.4%) patients were male.

This was similar to a study conducted in Saudi Arabia where 149 patients were included. There were 114 males and 35 females. Their age ranged 37–84 years with a mean of 59.2 years [14].

Within the same line, Dsouza and Smitha [15] reported that of the 100 patients, 39 (39%) were female and 61 (61%) were male. The majority of the patients fell between the ages of 51 and 70 years with a mean age of 60.76±9.66 years.

Malthesh et al. [16] in their study among diabetics and nondiabetic cases presented with ACSs, observed that the peak incidence of ACS in diabetics was in the fourth and fifth decade as compared with the fifth and sixth decade in nondiabetics.

On the other hand, the study did not reveal a significant difference between the two groups regarding age. The mean age of the included cases was 65.2 and 65.5 years in the diabetic and nondiabetic groups, respectively [17].

In the current study, there was no significant difference between the two groups regarding sex (P=0.361). Males represented 64.9 and 55.6% of cases in group A and group B, respectively.

The high prevalence of male sex is because we included patients presented with chest pain. Chest pain in the majority of cases is an indicator for CAD and previous studies agree with our findings regarding the increased prevalence of CAD in males [18],[19].

A previous study has also reported male sex as a major nonmodifiable risk factor for CAD [20].

In the current study, in group A, hypertension was present in 45% of the cases, dyslipidemia in 27.5% of the cases, and there were 40% smokers. Positive family history of DM was present in 17.5% of the cases.

Aljarid et al. [14] showed that hypertension was present in 85 (56.7%) patients. Their BMI ranged between 20.5 and 45.8 kg/m2, with a mean of 30.07. Current smoking was present in 70 (47%).

In the study conducted by Sayed et al. [21], smoking, positive family history of CAD, hypertension, and obesity were detected in 64.9, 43.3, 27, and 18.9% of the included cases, respectively.

In a meta-analysis of 19 studies by Ahmed and Al-Khaffaf [22], the most common atherosclerotic risk factor prevalent among patients in those studies was smoking (60%), followed by hypertension (47%), ischemic heart disease (34%), and DM (25.5%).

A total of 1056 patients were included in a Brazilian study to detect the risk factors for CAD. The following risk factors were reported in a descending manner as the following: obesity (68%), positive family history of CAD (50%), dyslipidemia (43%), hypertension (40%), smoking (23%), and DM (11%) [23].

In our study, smoking was detected in 40 and 55% of the cases in group A and group B, respectively, with no significant difference between the two groups (P=0.226).

Another study reported that smokers represented 18% of cases in both groups (P=0.54) [18]. Smoking was shown as a major risk factor for CAD. Moreover, smoking has been linked to atherosclerosis, myocardial infarction, and death in patients with CAD [24].

In our study, hypertension was detected in 45% of the cases in the two groups. In agreement with our findings, Laimoud et al. [25] reported no significant difference between the two groups regarding the prevalence of hypertension (P=0.23). It was present in 72 and 69.6% of cases in the diabetic and nondiabetic cases, respectively.

In our study, dyslipidemia was detected in 27.5 and 25% in group A and group B, respectively, with no statistically significant difference (P=0.822).

Within the same line, Rana and colleagues reported no significant difference between diabetic and nondiabetic cases regarding the prevalence of hyperlipidemia (P=0.61). It was present in 70% of cases in both groups.

On the other hand, Laimoud et al. [25] reported that the prevalence of hyperlipidemia was significantly higher in the diabetic group (84 vs. 39.4% of cases in the nondiabetic group; P=0.001).

In our study, cardiac chest pain was present in 33.8 and 25% in group A and group B, respectively, with no statistically significant difference (P=0.453).

Deseive et al. [17] reported no significant difference between the two groups regarding the presentation (P=0.52). Chest pain was the commonest complaint in both groups as it was reported by 33.3 and 38.3% of cases in both groups, respectively, and that agreed with our results. Other presentations included abnormal stress test, dyspnea at exertion, along with arrhythmia.

In the current study, according to coronary angioartery study, coronary obstruction was detected in 27 (33.8%) cases and five (25%) cases in group A and group B, respectively, with no statistically significant difference (P=0.453).

However, CT angiography revealed affection in 19 (23.8%) cases of the cases in group A with no affected cases in the nondiabetic group with a statistically significant difference between the two groups.

In accordance with our findings, Deseive et al. [17] reported that obstructive lesions were significantly more common in the diabetic group (50.9 vs. 38% of cases in the nondiabetic cases; P=0.02).

Reda et al. [26] reported that obstructive lesions were present in 40% of cases in the diabetic group, while they were present only in 20% of nondiabetic cases (P=0.026).

Furthermore, Rana et al. [18] also confirmed the previous findings as obstructive lesions were detected in 37% of the diabetic cases versus 27% of cases in the nondiabetic group.

In the study conducted by Maffei et al. [27], the highest prevalence of CAD was found in diabetic patients presented with typical angina as compared with cases who had other presentations.

This observation was supported by the findings of another study, whereby the pathological findings showed that DM was associated with a global coronary disease burden and a prevalence of high-grade atherosclerosis similar to that observed among nondiabetic persons with clinical CAD [28].

In our study, according to the results of coronary angiography, in the diabetic group, mid-segment was affected in seven (25.9%) cases and proximal segment in 20 (74.1%) cases, while in the nondiabetic group, the proximal segment was affected in all of the five (100%) cases. Also, according to the findings of CT angiography, in the diabetic group, mid-segment was affected in six (31.6%) cases and proximal segment in 13 (68.4%) cases.

In the present study, proximal lesions were predominate, which is an important finding regarding the substudy of the PROSPECT trial, which demonstrated that vulnerable plaques are frequently seen in the proximal coronary tree, followed by the mid-coronary tree and the least in the distal coronary tree [29].

In the current study, CT angiography revealed affection in 19 (23.8%) cases of the cases in the diabetic group with no affected cases in the nondiabetic group with a statistically significant difference between the two groups (P=0.011).

Our results agreed with Truong et al. [30] who showed that patients with DM were less likely to have a normal CCTA (32 vs. 50%, P=0.003) and had a higher rate of obstructive CAD with severe stenosis (19 vs. 9%, P=0.02) than those without DM.

CCTA studies comparing diabetic and nondiabetic patients, however, have consistently demonstrated higher rates of plaque, plaque severity, obstructive CAD, and multivessel CAD in the former group [18],[31],[32].

As shown by Min et al. [33] in their study that included 400 asymptomatic diabetic patients, no history of CAD where the maximum stenosis, the number of coronary arteries involved, and the segment stenosis score are associated with increased risk of developing adverse cardiac events. They showed that CCTA had high accuracy in the prediction of cardiac events.

The value of CCTA was further confirmed in another study that included 313 diabetic patients with known or suspected CAD in comparison with nondiabetic patients (N=303) [34]. DM and evidence of obstructive CAD (>50% coronary stenosis) were reported as independent predictors of outcome.

In the current study, calcium score more than 0 was present in 58.8 and 55% of the cases in the diabetic and nondiabetic groups, respectively. There was no statistically significant difference between the two groups (P=0.761). Also, there was no statistically significant difference in the calcium score between the cases in the two study groups (P=0.694).

The results of the current study are in agreement with the results of other researchers, who have documented that patients with diabetes have a higher prevalence and extent of coronary calcium than nondiabetic patients [35],[36].

Other researchers have studied the prevalence of significant coronary calcium score in patients with diabetes. They evaluated calcium in the coronary arteries of 139 consecutive diabetic patients and compared the calcium score with a randomly selected nondiabetic control group. They found that patients with diabetes had a significant increase in the prevalence of coronary artery calcification scores greater than 400 compared with the randomly selected and matched nondiabetic control groups [37].

In a recent study, calcium score was also significantly higher in diabetic patients [124.1 (IQR 9.6–454.1) vs. 44.9 (IQR 1.0–246.2), P<0.01]. Diabetic patients have significantly higher TPV burden when compared with a propensity-matched control group of patients without diabetes [17].Another Egyptian study also reported that coronary artery calcification score was significantly elevated in cases with type-2 diabetes (123), while it had mean values of 2 and 3 in type-I diabetes and controls, respectively (P=0.005) [26].

Natali et al. [38] in their study showed diabetic patients with atherosclerotic disease score higher on coronary compromise (the sum of all atherosclerotic lesions detected) than the nondiabetic: 352±232 versus 211±201 U, P value less than 0.0001, respectively.

Our results disagreed with that reported in the South Bay Heart Watch Study, which found that the baseline coronary calcium predicted risk in the nondiabetic subgroup, but not in the diabetic subgroup. They included 269 asymptomatic individuals and evaluated the calcium score in these patients, but they used EBCT, which may be the cause for the difference between the results of their study and our study [39].

Calcium scoring is an integral part of the evaluation of patients referred for MSCT. Calcium scoring is a more sensitive noninvasive tool for the assessment of CAD. In patients with high calcium scoring, significant CAD is suspected. The correlation between calcification with MSCT and angiography is also needed.

In the current study, there was a high statistically significant agreement between the findings of the CT angiography and coronary angiography results (P<0.001). CT angiography had sensitivity of 70.37%, specificity of 100%, PPV 100%, NPV 86.89%, and accuracy of 90%.

Previous study of MSCT-CA has focused primarily on its diagnostic accuracy for the detection of obstructive CAD in comparison with invasive coronary angiography and demonstrated a high sensitivity and NPV close to 100% [40].


  Conclusion Top


All in all, it is evident that DM is responsible for higher atherosclerotic burden in the coronary arteries. Additionally, cases presented with acute chest pain to emergency department; early use of CCTA has revealed high sensitivity for detecting the affected coronaries as compared with the utilization of ordinary coronary angiography.

Recommendations

Diabetic cases presenting with chest pain should be screened for CAD using CCTA. CCTA should be encouraged as a noninvasive diagnostic modality for coronary artery lesion. More studies including more cases should be conducted to clearly elucidate the diagnostic value of this modality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Walinjkar RS, Khadse S, Kumar S, Bawankule S, Acharya S. Platelet indices as a predictor of microvascular complications in type 2 diabetes. Indian J Endocrinol Metab 2019; 23:206.  Back to cited text no. 1
    
2.
Animaw W, Seyoum Y. Increasing prevalence of diabetes mellitus in a developing country and its related factors. PLoS ONE 2017; 12:e0187670.  Back to cited text no. 2
    
3.
Inzucchi S, Bergenstal R, Fonseca V, Gregg E, Mayer-Davis B, Spollett G et al. Diagnosis and classification of diabetes mellitus. Diabetes Care 2010; 33:S62–S69.  Back to cited text no. 3
    
4.
Kassem HK, Dabees NL, El-Sheikh AA, Hegab MS, Dawoud RM, Mansour HM. Multislice CT coronary angiography is an additional tool for provisional diagnosis of acute chest pain with neither ECG nor echocardiography significant findings in emergency room. Tanta Med J 2015; 43:113.  Back to cited text no. 4
  [Full text]  
5.
Fox CS, Golden SH, Anderson C, Bray GA, Burke LE, De Boer IH et al. Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation 2015; 132:691–718.  Back to cited text no. 5
    
6.
Johnston CA, Moreno JP, Foreyt JP. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. Curr Atheroscler Rep 2014; 16:457.  Back to cited text no. 6
    
7.
Branch KR, Hira R, Brusen R, Maynard C, Kudenchuk PJ, Petek BJ et al. Diagnostic accuracy of early computed tomographic coronary angiography to detect coronary artery disease after out-of-hospital circulatory arrest. Resuscitation 2020; 153:243–250.  Back to cited text no. 7
    
8.
Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM, Maron DJ et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease: a report of the American College of Cardiology appropriate use criteria task force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol 2017; 69:2212–2241.  Back to cited text no. 8
    
9.
Guaricci AI, Pontone G, Brunetti ND, De Rosa F, Montrone D, Guglielmo M et al. The presence of remodeled and mixed atherosclerotic plaques at coronary ct angiography predicts major cardiac adverse events—The café-pie study. Int J Cardiol 2016; 215:325–331.  Back to cited text no. 9
    
10.
SCOT-HEART investigators. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. Lancet 2015; 385:2383–2391.  Back to cited text no. 10
    
11.
Andreini D, Martuscelli E, Guaricci AI, Carrabba N, Magnoni M, Tedeschi C et al. Clinical recommendations on Cardiac-CT in 2015: a position paper of the Working Group on Cardiac-CT and Nuclear Cardiology of the Italian Society of Cardiology. J Cardiovasc Med 2016; 17:73–84.  Back to cited text no. 11
    
12.
Shaw LJ, Chandrashekhar Y, Narula J. Risk detection among asymptomatic patients with diabetes: is it time for a varied approach?. Washington, DC: American College of Cardiology Foundation; 2016.  Back to cited text no. 12
    
13.
Akalu Y, Birhan A. Peripheral arterial disease and its associated factors among type 2 diabetes mellitus patients at Debre Tabor general hospital, Northwest Ethiopia. J Diabetes Res 2020; 2020:9419413.  Back to cited text no. 13
    
14.
Aljarid JS, Alazmi AM, Almaeen AH, Alruwaili AO, Ragheb MM. Prevalence and pattern of peripheral arterial disease among diabetic individual in Al-jouf Region. Egypt J Hosp Med 2018; 73:6641–6645.  Back to cited text no. 14
    
15.
Dsouza NV, Smitha B. Coronary artery disease in patients with type 2 diabetes mellitus: correlating ankle brachial pressure index with coronary angiography. J Cardiovasc Dis Res 2018; 9:141–145.  Back to cited text no. 15
    
16.
Malthesh M, Sakib T, Mallesh P. Coronary artery involvement in diabetic and non-diabetic patients with acute coronary syndrome. Int J Sci Study 2016; 3:295–298.  Back to cited text no. 16
    
17.
Deseive S, Straub R, Kupke M, Broersen A, Kitslaar PH, Stocker TJ et al. Impact of diabetes on coronary artery plaque volume by coronary CT angiography and subsequent adverse cardiac events. J Cardiovasc Comp Tomography 2019; 13:31–37.  Back to cited text no. 17
    
18.
Rana JS, Dunning A, Achenbach S, Al-Mallah M, Budoff MJ, Cademartiri F et al. Differences in prevalence, extent, severity, and prognosis of coronary artery disease among patients with and without diabetes undergoing coronary computed tomography angiography: results from 10, 110 individuals from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes): an InteRnational Multicenter Registry. Diabetes Care 2012; 35:1787–1794.  Back to cited text no. 18
    
19.
Bharath S, Gosavi S. Angiography findings in diabetic and non-diabetic patients with cardiac symptoms. J Cardiovasc Dis Res 2020; 11:60–63.  Back to cited text no. 19
    
20.
Gheisari F, Emami M, Raeisi Shahraki H, Samipour S, Nematollahi P. The role of gender in the importance of risk factors for coronary artery disease. Cardiol Res Pract 2020; 2020:6527820.  Back to cited text no. 20
    
21.
Sayed A, Ahmed SM, Abdelalim AM, Nagah M, Khairy H. Is peripheral arterial disease associated with carotid artery disease in Egyptians? A pilot study. Egypt J Neurol Psychiatry Neurosurg 2016; 53:12.  Back to cited text no. 21
    
22.
Ahmed B, Al-Khaffaf H. Prevalence of significant asymptomatic carotid artery disease in patients with peripheral vascular disease: a meta-analysis. Eur J Vasc Endovasc Surg 2009; 37:262–271.  Back to cited text no. 22
    
23.
Gus I, Ribeiro RA, Kato S, Bastos J, Medina C, Zazlavsky C et al. Variations in the prevalence of risk factors for coronary artery disease in Rio Grande do Sul-Brazil: a comparative analysis between2002 and 2014. Arq Bras Cardiol 2015; 105:573–579.  Back to cited text no. 23
    
24.
Inoue T. Cigarette smoking as a risk factor of coronary artery disease and its effects on platelet function. Tob Induc Dis 2004; 2:27.  Back to cited text no. 24
    
25.
Laimoud M, Faris F, Elghawaby H. Intravascular evaluation of coronary atherosclerotic lesions among Egyptian diabetic patients with acute coronary syndromes. Egypt Heart J 2018; 70:237–241.  Back to cited text no. 25
    
26.
Reda AA, Al Kersh AM, Al Sherif MM. Extent of coronary atherosclerosis in diabetic and nondiabetic patients by multislice CT calcium scoring. Menouf Med J 2016; 29:437.  Back to cited text no. 26
    
27.
Maffei E, Seitun S, Martini C, Guaricci AI, Tarantini G, van Pelt N et al. Prognostic value of CT coronary angiography in diabetic and non-diabetic subjects with suspected CAD: importance of presenting symptoms. Insights Imaging 2011; 2:25–38.  Back to cited text no. 27
    
28.
Goraya TY, Leibson CL, Palumbo PJ, Weston SA, Killian JM, Pfeifer EA et al. Coronary atherosclerosis in diabetes mellitus: a population-based autopsy study. J Am Coll Cardiol 2002; 40:946–953.  Back to cited text no. 28
    
29.
Otsuka K, Fukuda S, Tanaka A, Nakanishi K, Taguchi H, Yoshikawa J et al. Napkin-ring sign on coronary CT angiography for the prediction of acute coronary syndrome. JACC: Cardiovasc Imag 2013; 6:448–457.  Back to cited text no. 29
    
30.
Truong QA, Schulman‐Marcus J, Zakroysky P, Chou ET, Nagurney JT, Fleg JL et al. Coronary CT angiography versus standard emergency department evaluation for acute chest pain and diabetic patients: is there benefit with early coronary CT angiography? Results of the randomized comparative effectiveness ROMICAT II Trial. J Am Heart Assoc 2016; 5:e003137.  Back to cited text no. 30
    
31.
de Araújo Gonçalves P, Garcia-Garcia HM, Carvalho MS, Dores H, Sousa PJ, Marques H et al. Diabetes as an independent predictor of high atherosclerotic burden assessed by coronary computed tomography angiography: the coronary artery disease equivalent revisited. Int J Cardiovasc Imaging 2013; 29:1105–1114.  Back to cited text no. 31
    
32.
Kamimura M, Moroi M, Isobe M, Hiroe M. Role of coronary CT angiography in asymptomatic patients with type 2 diabetes mellitus. Int Heart J 2012; 53:23–28.  Back to cited text no. 32
    
33.
Min JK, Labounty TM, Gomez MJ, Achenbach S, Al-Mallah M, Budoff MJ et al. Incremental prognostic value of coronary computed tomographic angiography over coronary artery calcium score for risk prediction of major adverse cardiac events in asymptomatic diabetic individuals. Atherosclerosis 2014; 232:298–304.  Back to cited text no. 33
    
34.
Van Werkhoven JM, Cademartiri F, Seitun S, Maffei E, Palumbo A, Martini C et al. Diabetes: prognostic value of CT coronary angiography—comparison with a nondiabetic population. Radiology 2010; 256:83–92.  Back to cited text no. 34
    
35.
Hoff JA, Quinn L, Sevrukov A, Lipton RB, Daviglus M, Garside DB et al. The prevalence of coronary arterycalcium among diabetic individuals without known coronary artery disease. J Am Coll Cardiol 2003; 41:1008–1012.  Back to cited text no. 35
    
36.
Raggi P, Shaw LJ, Berman DS, Callister TQ. Prognostic value of coronary artery calcium screening in subjects with and without diabetes. J Am Coll Cardiol 2004; 43:1663–1669.  Back to cited text no. 36
    
37.
Schurgin S, Rich S, Mazzone T. Increased prevalence of significant coronary artery calcification in patients with diabetes. Diabetes Care 2001; 24:335–338.  Back to cited text no. 37
    
38.
Natali A, Vichi S, Landi P, Severi S, L’abbate A, Ferrannini E. Coronary atherosclerosis in type II diabetes: angiographic findings and clinical outcome. Diabetologia 2000; 43:632–641.  Back to cited text no. 38
    
39.
Qu W, Le TT, Azen SP, Xiang M, Wong ND, Doherty TM et al. Value of coronary artery calcium scanning by computed tomography for predicting coronary heart disease in diabetic subjects. Diabetes Care 2003; 26:905–910.  Back to cited text no. 39
    
40.
Maffei E, Palumbo A, Martini C, Meijboom W, Tedeschi C, Spagnolo P et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography in a large population of patients without revascularisation: registry data and review of multicentre trials. Radiol Med (Torino) 2010; 115:368–384.  Back to cited text no. 40
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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