CACS and CAD in healthy subjects, uncomplicated type 2 diabetic patients, type 2 diabetic patients with autonomic neuropathy and type 2 diabetic subjects with Charcot osteoarthropthy: the prognostic cardiovascular role of Charcot foot Poster No.: C-2120 Congress: ECR 2012 Type: Scientific Paper Authors: G. Verrillo, R. Marano, G. SAVINO, D. Pitocco, V. Silvestri, A. Meduri, B. Merlino, L. Bonomo; Rome/IT Keywords: DOI: Cardiac, Cardiovascular system, CT-Angiography, Diagnostic procedure, Arteriosclerosis 10.1594/ecr2012/C-2120 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 16
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Purpose To explore the differences in Coronary Artery Calcium Score (CACS) and Coronary Artery Disease (CAD) assessed by Multidetector Computed Tomography (MDCT) in three different subsets of diabetic patients: uncomplicated type 2 diabetic patients; type 2 diabetic patients with Autonomic Neuropathy (AN); type 2 diabetic patients with Charcot Osteoarthropathy (CO); in comparison with control subjects (non diabetic). Methods and Materials Coronary Artery Calcium (CAC) is an integral part of atherosclerotic coronary heart disease (CHD) and several studies support the role of CAC Score (CACS) for prediction of myocardial infarction and cardiovascular mortality. Nevertheless data about the effective role played by the screening of ischemic heart disease in Asymptomatic subjects are contrasting. Type 2 diabetic subjects have an increased cardiovascular mortality and the presence of diabetes has been considered to be equivalent to an ischemic event. This elevated risk is linked to an accelerated vascular atherosclerosis, in particular coronary atherosclerosis, but the utility of screening in such patients for Asymptomatic CAD is still controversial. Charcot Osteoarthropathy (CO) and Diabetes with Autonomic Neuropathy (AN) are significantly associated with higher mortality risk than diabetes alone (Fig. 1 on page 4). Forty patients have been enrolled: 10 non diabetic subjects; 10 uncomplicated type 2 diabetic patients; 10 type 2 diabetic patients with AN; 10 type 2 diabetic patients with CO. Page 3 of 16
The study protocol was approved by our institutional review board and written informed consent was obtained from all patients. The diagnosis of AN was made with cardiovascular tests. The CO was defined according to symptoms, and clinical and radiological signs. All patients underwent MDCT for: - CACS (sequential 64-DCT scan with prospective-ecg gating) (Fig. 2 on page 4) (Fig. 3 on page 5)(Fig. 4 on page 6); - CAD assessment (spiral 64-DCT scan with retrospective-ecg gating). Coronary Angiography was the Standard of Reference (SOR) for CAD assessment, if available. Images for this section: Fig. 1: Background Page 4 of 16
Fig. 2: Agatston Score for Coronary Artery Calcium Page 5 of 16
Fig. 3: Alternative Score for Coronary Artery Calcium Page 6 of 16
Fig. 4: From the Consensus Statement on CACS Page 7 of 16
Results The three diabetic groups did not present significant differences about the variables known to influence coronary ATS (age, sex, time-disease, lipid profiles, HbA1c, waist-tohip ratio). Fig. 5 on page 8 Comparing diabetics with the controls, only HbA1c was significantly different (p<0.001). All CO and diabetic patients with AN had a cardiovascular autonomic score >5 compared to controls and uncomplicated diabetics (all <2; p<0.001). Total CACS was significantly higher in diabetic patients compared to controls, without significative differences among the three diabetic groups. Fig. 6 on page 9 The rate of coronary stenosis >50% (significant stenosis) was higher in CO patients compared with no-co patients (79 vs 52%; p<0.05). Fig. 7 on page 10 Case 1: CO Patient. CACS (Agatston)= 482, with a severe stenosis of mid Right Coronary Artery (RCA), well shown on 2D/3D images and cross-section view, with coronary angiography correlation pre- and post-treatment. Fig. 8 on page 11 Case 2: CO Patient. CACS (Agatston)= 1020, with a severe stenosis of a large first Marginal Obtuse (OM) branch well shown on 2D/3D images and cross-section view, with coronary angiography correlation pre- and post-treatment. Fig. 9 on page 12 Images for this section: Page 8 of 16
Fig. 5: Results 1: table of variables known to influence coronary ATS. Page 9 of 16
Fig. 6: Results 2: plot of CACS in all groups of patients. OC: type 2 diabetic patients with Charcot Osteoarthropathy; AN: type 2 diabetic patients with Autonomic Neuropathy; DM: uncomplicated type 2 diabetic patients; No-DM: control patients. Page 10 of 16
Fig. 7: Results 3: rate of significant (>50%) coronary artery stenosis. Page 11 of 16
Fig. 8: Case 1: CO Patient, with CACS (Agatston)= 482 and a severe stenosis of mid Right Coronary Artery (RCA), well shown on 2D/3D images and cross-section view, with coronary angiography correlation pre- and post-treatment. Page 12 of 16
Fig. 9: Case 2: CO Patient with CACS (Agatston)= 1020 and a severe stenosis of a large first Marginal Obtuse (OM) branch, well shown on 2D/3D images and cross-section view, with coronary angiography correlation pre- and post-treatment. Page 13 of 16
Conclusion Type-2 DM increases CHD mortality, and its presence has been considered an ischemicequivalent. MDCT is helpful for the assessment of diabetic subjects with Charcot Osteoarthropathy. The study supports previous findings about CACS in diabetic subjects and underlines that Charcot Osteoarthropathy could be considered a prognostic marker for more severe CAD. Further, larger and hard-points study are necessary to confirm these data. References Agatston AS, Janowitz W, Hildner FJ, Zusmer NR, Viamonte M, Detrano R (1990) Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 15:827-832 McCollough CH, Ulzheimer S, Halliburton SS, Shanneik K, White RD, Kalender WA, For the International Consortium on Standardization in Cardiac CT (2007) Coronary Artery Calcium: A Multi-institutional, Multi-manufacturer International Standard for Quantification at Cardiac CT. Radiology 243(2):527-538 O'Rourke RA, Brundage BH, Froelicher VF, Greenland P, Grundy SM, Hachamovitch R, Pohost GM, Shaw LJ, Weintraub WS, Winters WL Jr (2000) American College of Cardiology/American Heart Association Expert Consensus document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease. 4;102(1):126-140 Greenland P, Bonow RO, Brundage BH, Budoff MJ, Eisenberg MJ, Grundy SM, Lauer MS, Post WS, Raggi P, Redberg RF, Rodgers GP, Shaw LJ, Taylor AJ, Weintraub WS (2007) ACCF/AHA 2007 Clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Page 14 of 16
Committee to Update the 2000 Expert Consensus Document on Electron-Beam Computed Tomography). Circulation 115:402-426 Oudkerk M, Stillman AE, Halliburton SS, Kalender WA, Möhlenkamp S, McCollough CH, Vliegenthart R, Shaw LJ, Stanford W, Taylor AJ, van Ooijen PMA, Wexler L, Raggi P (2008) Coronary artery calcium screening: current status and recommendations from the European Society of Cardiac Radiology and North American Society for Cardiovascular Imaging. Eur Radiol 18:2785-2807 Young LH, Wackers FJ, Chyun DA, Davey JA, Barrett EJ, Taillefer R, Heller GV, Iskandrian AE, Wittlin SD, Filipchuk N, Ratner RE, Inzucchi SE; DIAD Investigators (2009) Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study: a randomized controlled trial. JAMA 301(15):1547-1555 Sohn MW, Lee TA, Stuck RM, Frykberg RG, Budiman-Mak E (2009) Mortality Risk of Charcot Arthropathy Compared With that of Diabetic Foot Ulcer and Diabetes Alone. Diabetes Care 32(5):816-821 Gazis A, Pound N, Macfarlane R, Treece K, Game F, Jeffcoate W (2004) Mortality in patients with diabetic neuropathic osteoarthropathy (Charcot foot). Diabet Med 21(11):1243-1246 van Baal J, Hubbard R, Game F, Jeffcoate W (2010) Mortality associated with acute Charcot foot and neuropathic foot ulceration. Diabetes Care 33(5):1086-1089 Personal Information Gemma Verrillo, MD (gemma_verrillo@hotmail.com) Riccardo Marano, MD Giancarlo Savino, MD Dario Pitocco, MD Valentina Silvestri, MD Agostino Meduri, MD Page 15 of 16
Biagio Merlino, MD Lorenzo Bonomo, MD Department of Bioimaging and Radiological Sciences Institute of Radiology Catholic University of Rome "A. Gemelli" University Hospital L.go Agostino Gemelli 8, 00168 - Rome, Italy Phone: +39 06 30156054 Fax: +39 06 35501928 Page 16 of 16