The duration of diabetes influences the development of CAD in patients with type 1 diabetes, but such a relationship has not been demonstrated in those with type 2. Therefore, it is unclear whether the duration of asymptomatic hyperglyce-mia, or the state of impaired glucose tolerance, may have an important role on the development of CAD preceding the overt manifestations of type 2 diabetes (31,32). Several studies have shown that the mortality rate due to CAD was higher in patients with impaired glucose tolerance compared to normoglycemic men, although it was smaller when compared to that of patients with overt diabetes. At least one study has demonstrated that the risk of CAD increases linearly with fasting blood glucose levels in patients with impaired glucose tolerance, whereas the fasting insulin level has been implicated as a possible independent risk factor for CAD mortality in another study. Early impairment of LV diastolic function has been documented not only in patients with type 2 diabetes, but also in those with impaired glucose tolerance, independent of the confounding role of myocar-dial ischemia, body weight, and levels of arterial blood pressure (33). Similarly, early atherosclerotic changes, as well as borderline impairment of cardiac auto-nomic function, could be demonstrated in those subjects with impaired glucose tolerance. The various diagnostic tests previously reviewed that are useful in the diagnosis of heart disease in patients with previously diagnosed diabetes can also be applied to those with impaired glucose tolerance or prediabetic states, although the clinical benefits and cost effectiveness of a strategy directed to screen for early cardiac abnormalities in asymptomatic subjects with prediabetic states or impaired glucose tolerance remains to be established.
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