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Myocardial infarction is often silent in diabetic patients, probably as often as it is symptomatic [1]. Major arguments stand in favor of screening patients for silent myocardial ischemia (SMI), including the predictive value of SMI for cardiovascular events above and beyond risk scores [2], with the poorest prognosis in patients with extended ischemia and/or coronary stenoses [3]. However, a controversy has recently emerged with regard to the usefulness of screening, based on the improvement of cardiovascular prognosis in the diabetic population, feasibility and costeffectiveness concerns, and the lack of evidence for a benefit of screening on outcomes. In fact, treatment intensification targeting the major risk factors reduces by 50% the rate of cardiovascular events but allows a high residual risk which may be related to silent coronary artery disease (CAD). Regarding the second argument, given the huge number of diabetic patients, it is neither possible nor logical to screen all of them for SMI. Thus, a careful patient selection based on coronary risk stratification is mandatory. In this issue of Endocrine, the article by Gazzaruso et al. [4] addresses the question of the effectiveness of screening for CAD. The authors screened 299 consecutive men with newly diagnosed type 2 diabetes (T2D) without heart or peripheral artery disease. SMI was detected by an ECG stress test with a subsequent confirmation based mostly upon defects on stress myocardial scintigraphy, and CAD was assessed on angiography in the patients with confirmed SMI. SMI prevalence was around 27%, and the prevalence of coronary stenoses C50% of the lumen was around 25%. In another Italian study performed in patients with the same characteristics, the rate of SMI according to the ECG stress test was quite similar in men [5]. In the MiSAD study also performed in Italy, which included patients with long-standing diabetes, SMI as defined by the same two tests was found in only around 8% of men [6]. In several studies, patients with long-standing diabetes and other risk factors, many of whom also had peripheral artery disease and nephropathy, were all screened by stress myocardial scintigraphy or stress echocardiography. The rate of SMI was usually 20–35%, and CAD was found in oneto two-thirds of those with SMI, i.e., in 10–15% of the overall cohorts [3]. Therefore, the rates of SMI in newly diagnosed T2Ds are surprisingly high. This suggests that some patients had previously undiagnosed diabetes and is also consistent with the ‘‘common soil’’ hypothesis for T2D and CAD. The fact that SMI or CAD is not more prevalent in higher-risk patients with long-standing diabetes might result from the beneficial effects of antidiabetic treatment and treatment risk factors. As expected, screening without subsequent therapeutic adaptation, including or not including coronary revascularization, does not appear to affect overall outcomes [7]. One pilot randomized study and one retrospective study suggest that revascularization may be beneficial to patients with SMI [3]. However, the benefit of stable CAD has recently been questioned. Therefore, a major challenge is to identify patients with severe CAD who are most likely to benefit from coronary artery bypass grafting, as shown in the BARI-2D trial. Improving the cost-effectiveness of screening will allow us to detect such patients while performing fewer investigations in a lower P. Valensi Department of Endocrinology-Diabetology-Nutrition AP-HP, Jean Verdier Hospital, Paris-Nord University, CRNH-IdF, Bondy, France

Looking after silent coronary artery disease in diabetic patients. When and how?