Coronary Atherosclerosis Across the Glycemic Spectrum in Asymptomatic Adults

Coronary atherosclerosis became progressively more common as glycemic status worsened.

Coronary plaque was present in 43% of participants with normal glucose regulation. It increased to 58% in prediabetes and 69% in diabetes.

The association remained after adjustment for other cardiovascular risk factors.

Compared with normal glucose regulation, prediabetes was associated with 30% higher odds of coronary plaque. Diabetes was associated with 75% higher odds.

Prediabetes and diabetes were also associated with more non-calcified plaque and high-risk plaque.

Diabetes showed the strongest association with coronary narrowing. It was associated with approximately threefold higher odds of stenosis ≥50%.

Important findings were also seen among participants with diabetes who appeared to be at low cardiovascular risk.

Among those with an estimated 10-year cardiovascular risk below 5%, 46% had coronary plaque. 10% had stenosis ≥50%.

A similar finding emerged among participants with diabetes and no detectable coronary calcium. 30% still had coronary plaque. 3% had stenosis ≥50%.

The study shows a clear relationship between metabolic health and coronary atherosclerosis.

This relationship was already visible in prediabetes. Coronary plaque was substantially more common than in people with normal glucose regulation.

Diabetes was associated with an even greater burden of disease. This included non-calcified plaque, high-risk plaque and significant coronary narrowing.

The findings are important for long-term cardiovascular prevention. They suggest that changes in glucose regulation may accompany coronary atherosclerosis before cardiovascular symptoms develop.

They also show the limitations of looking at a single risk measure. Low estimated cardiovascular risk did not exclude coronary plaque in participants with diabetes. Neither did the absence of detectable coronary calcium.

This study does not show that prediabetes or diabetes directly caused the coronary changes. It was a cross-sectional observational study.

It also does not establish coronary CT angiography as a routine screening test for people with prediabetes or diabetes.

However, the study identified a consistent gradient. Worse glycemic status was associated with more extensive and higher-risk coronary atherosclerosis.

The findings in diabetes are particularly relevant. Some participants classified as having low estimated cardiovascular risk already had coronary plaque or significant coronary narrowing.

Coronary calcium provided additional information. In participants with diabetes, it was more closely associated with coronary CT findings than estimated cardiovascular risk. It was also informative in a larger proportion of participants.

Yet the absence of coronary calcium did not completely exclude disease. Almost one-third of participants with diabetes and no detectable coronary calcium still had coronary plaque.

The study therefore supports an individualized cardiovascular assessment in people with abnormal glucose regulation. Metabolic status, traditional cardiovascular risk and evidence of subclinical atherosclerosis provide different information.