Clin Cardiol. 2026 Oct;49(10):e70470. doi: 10.1002/clc.70470.
ABSTRACT
INTRODUCTION: Diabetes mellitus markedly increases atherosclerotic cardiovascular risk, and coronary artery disease remains a leading cause of morbidity and mortality. Silent myocardial ischemia (SMI) is clinically relevant in diabetes because autonomic dysfunction and altered pain perception may attenuate typical ischemic symptoms; however, the clinical benefit of routine screening in asymptomatic individuals without known coronary artery disease (CAD) remains uncertain.
OBJECTIVE: To evaluate whether systematic screening for silent myocardial ischemia or occult CAD in asymptomatic adults with diabetes and no known CAD improves major cardiovascular outcomes.
METHODS: We performed a systematic review of studies published from January 1, 2000 through March 31, 2025. The primary effectiveness synthesis included randomized trials comparing systematic screening with no systematic screening or usual care. Primary outcomes were major adverse cardiovascular events (MACE), cardiovascular mortality, and all-cause mortality; secondary outcomes included detection yield, downstream testing or revascularization, and reported screening-related harms. Compatible study-level hazard ratios (HRs) and risk ratios (RRs) were synthesized on the log scale using random-effects inverse-variance meta-analysis, with heterogeneity and sensitivity analyses prespecified. The review was not prospectively registered.
RESULTS: Five RCTs (n = 3315; DIAD, DYNAMIT, FACTOR-64, DADDY-D, and the pilot trial by Faglia et al.) met the eligibility criteria. Screening did not significantly reduce major cardiovascular outcomes in the four trials included in the quantitative synthesis (pooled HR/RR 0.76; 95% CI 0.48-1.19). DYNAMIT was synthesized narratively because its published primary composite was not directly harmonizable with the pooled endpoint. Reporting of false-positive results and procedure-related harms was incomplete and heterogeneous.
CONCLUSIONS: In asymptomatic adults with diabetes and no known CAD, routine screening detects occult ischemia or atherosclerosis but has not demonstrated a reduction in MACE or mortality compared with the trial-era usual-care or protocol-defined medical-management strategies studied. These findings do not support routine population-wide screening; selective testing is most defensible when the result is expected to change management.
PMID:42831381 | DOI:10.1002/clc.70470