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A 43-year-old man with type 2 diabetes mellitus was referred for cardiovascular risk assessment 2 years ago. Other risk factors for coronary artery disease included hypercholesterolemia, smoking, and a family history of coronary artery disease.The patient was asymptomatic. Physical examination was unremarkable; his body mass index was 22 kg/m2 and his blood pressure was 125/80 mm Hg. Hypercholesterolemia was well regulated with statin administration (total cholesterol 3.52 mmol/L, low-density lipoprotein cholesterol 2.23 mmol/L, high-density lipoprotein cholesterol 0.94 mmol/L). ECG showed normal sinus rhythm and no additional abnormalities (Figure 1). Figure 1. ECG showing sinus rhythm and no abnormalities.Myocardial perfusion imaging was performed with gated single-photon emission computed tomography (SPECT) using technetium-99m sestamibi (500 MBq). Pharmacological stress was induced with adenosine; the stress ECG showed no abnormalities. On gated SPECT, left ventricular ejection fraction was 68% during stress as well as at rest; myocardial perfusion imaging revealed no perfusion abnormalities during stress or at rest (Figure 2). Figure 2. SPECT myocardial perfusion imaging reveals normal perfusion at stress …

The Difficulty of Adequate Risk Stratification for Patients With Asymptomatic Diabetes