Screening for the Presence of Coronary Artery Disease

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Paul Poirier MD, PhD, FRCPC, FACC, FAHA Robert Dufour MD, MSc André Carpentier MD, FRCPC, CSPQ Éric Larose MD, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • Compared to people without diabetes, people with type 1 and type 2 (especially women) are at higher risk of developing heart disease, and at an earlier age. Unfortunately, a large proportion will have no symptoms before either a fatal or a nonfatal myocardial infarction (MI). Hence, it is desirable to identify patients at high risk for vascular events, especially patients with established severe coronary artery disease (CAD).
  • In individuals at high risk of CAD (based on age, gender, description of chest pain, history of prior MI, abnormal resting electrocardiogram and presence of several other risk factors), exercise stress testing is useful for the assessment of prognosis.
  • Exercise capacity is frequently impaired in people with diabetes due to the high prevalence of obesity, sedentary lifestyle, peripheral neuropathy (both sensory and motor) and vascular disease. For those unable to perform an exercise test, functional imaging testing, such as pharmacologic or nuclear stress imaging, may be required. Most imaging techniques have been shown useful in prospective study in order to identify patients at higher risk. However, there is, so far, no head-to-head study showing which one will be best in a cost-effective way.

Highlights of Revisions

  • A new recommendation suggests that a repeat resting electrocardiogram (ECG) should be performed every 2 years in patients with type 2 diabetes rather than just in individuals at high risk for cardiovascular (CV) events as stated in 2008.

Recommendations

  1. 1.A baseline resting ECG should be performed in individuals with any of the following [Grade D, Consensus]:
    • Age >40 years
    • Duration of diabetes >15 years and age >30 years
    • End organ damage (microvascular, macrovascular)
    • Cardiac risk factors
  2. 2.A repeat resting ECG should be performed every 2 years in patients with diabetes [Grade D, Consensus].
  3. 3.People with diabetes should undergo investigation for CAD by exercise ECG stress testing as the initial test [Grade D, Consensus] in the presence of the following:
    • Typical or atypical cardiac symptoms (e.g. unexplained dyspnea, chest discomfort) [Grade C, Level 3 (1)]
    • Signs or symptoms of associated diseases
      • Peripheral arterial disease (abnormal ankle-brachial index) [Grade D, Level 4 (2)]
      • Carotid bruits [Grade D, Consensus]
      • Transient ischemic attack [Grade D, Consensus]
      • Stroke [Grade D, Consensus]
    • Resting abnormalities on ECG (e.g. Q waves) [Grade D, Consensus]
  4. 4.Pharmacological stress echocardiography or nuclear imaging should be used in individuals with diabetes in whom resting ECG abnormalities preclude the use of exercise ECG stress testing (e.g. left bundle branch block or ST-T abnormalities) [Grade D, Consensus]. In addition, individuals who require stress testing and are unable to exercise should undergo pharmacological stress echocardiography or nuclear imaging [Grade C, Level 3 (3)].
  5. 5.Individuals with diabetes who demonstrate ischemia at low exercise capacity (<5 metabolic equivalents [METs]) on stress testing should be referred to a cardiac specialist [Grade D, Consensus].

Abbreviations:
CAD , coronary artery disease; ECG , electrocardiogram.

References

  1. Zellweger MJ, Hachamovitch R, Kang X, et al. Prognostic relevance of symptoms versus objective evidence of coronary artery disease in diabetic patients. Eur Heart J 2004;25:543-50.
  2. Bacci S, Villella M, Villella A, et al. Screening for silent myocardial ischaemia in type 2 diabetic patients with additional atherogenic risk factors: applicability and accuracy of the exercise stress test. Eur J Endocrinol 2002;147:649-54.
  3. Shaw LJ, Iskandrian AE. Prognostic value of gated myocardial perfusion SPECT. J Nucl Cardiol 2004;11:171-85.

 

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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