The overall annual event rates in both the control and intervention groups were low, at less than 2% per year. This may be attributed to the excellent medical management received by all patients, as evidenced by baseline levels near or exceeding system targets for HbA1c, LDL cholesterol, and systolic BP, Dr. Muhlestein said.
In an accompanying editorial (JAMA 2014 Nov. 17 [doi: 10.1001/jama.2014.15958]), Dr. Raymond Gibbons of the Mayo Clinic in Rochester, Minn., agreed that the findings are likely explained by the excellent baseline medical therapy.
“The data in this study suggest that Intermountain Healthcare has set a new published standard for what is achievable in patients with diabetes with respect to blood pressure control and lipid-lowering therapy and that, when therapy is applied this effectively, patients with diabetes are no longer at high risk for major cardiovascular events,” Dr. Gibbons wrote.
Invited discussant Dr. Pamela Douglas, professor of medicine at Duke University in Durham, N.C., said the key message is that the study was tested in a highly managed population, but that nationally less than 10% of diabetes patients are at goal for cardiovascular protection.
Dr. Douglas said CCTA screening may still have a limited role in asymptomatic patients if used to help patients adhere to treatment strategies that can improve outcomes. “This may be a bit roundabout, but that’s the one time,” she added.
Dr. Douglas also called for improved risk-prediction tools to identify even higher-risk individuals, observing that events were not confined to those with obstructive disease.
“We need to be looking for nonobstructive disease, which was in fact the hypothesis of this trial,” she said. “So perhaps we need to look beyond ischemia, beyond atherosclerosis to vulnerable plaque ... and cell targets.”
During the roundtable discussion of the study, panelists suggested that a coronary calcium score could play a role in identifying these higher-risk patients, and that telling a patient they have a calcium score of 800 may also get even the most stubborn diabetes patient to actually take their medications.
The study was supported by the Intermountain Research and Medical Foundation, Intermountain Heart Institute, and grants from Toshiba and Bracco. The study authors reported having no financial disclosures. Dr. Gibbons reported serving as a consultant for Lantheus Medical Imaging. Dr. Douglas reported no conflicts.