Cardiac Computed Tomography for Personalized Management of Patients with Type 2 Diabetes Mellitus

The incidence and prevalence of type 2 diabetes mellitus are increasing in the United States and worldwide. The individual-level risk of atherosclerotic cardiovascular disease events in primary prevention populations with type 2 diabetes mellitus is highly heterogeneous. Accurate risk stratification in this group is paramount to optimize the use of preventive therapies. Herein, we review the use of the coronary artery calcium score as a decision aid in individuals with type 2 diabetes mellitus without clinical atherosclerotic cardiovascular disease to guide the use of preventive pharmacotherapies, such as aspirin, lipid-lowering mediations, and cardiometabolic agents. The magnitude of expected risk reduction for each of these therapies must be weighed against its cost and potential adverse events. Coronary artery calcium has the potential to improve risk stratification in select individuals beyond clinical and laboratory risk factors, thus providing a more granular assessment of the expected net benefit with each therapy. In patients with diabetes mellitus and stable chest pain, coronary computed tomography angiography increases the sensitivity for coronary artery disease diagnoses compared with functional studies because of the detection of nonobstructive atherosclerosis. Most importantly, this anatomic approach may improve cardiovascular outcomes by increasing the use of evidence-based preventive therapies informed by plaque burden. We therefore provide an updated discussion of the pivotal role of coronary computed tomography angiography in the workup of stable chest pain in patients with diabetes mellitus in the context of recent landmark trials, such as PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), SCOT-HEART trial (Scottish Computed Tomography of the Heart), and ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches). Finally, we also outline the current role of coronary computed tomography angiography in acute chest pain presentations.