2008 Clinical Practice Guidelines - Canadian Diabetes Association

More documents

Recommendations

Info

2008 CLINICAL PRACTICE GUIDELINES S98 imaging and coronary calcium scoring. J Nucl Cardiol. 2006; 13:11-18. 32. Wackers FJ, Young LH, Inzucchi SE, et al; Detection of Ischemia in Asymptomatic Diabetics Investigators. Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study. Diabetes Care. 2004;27:1954-1961. 33. Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology & Metabolism. UKPDS Risk Engine. Diabetes Trials Unit, University of Oxford website.Available at: http:// www.dtu.ox.ac.uk/riskengine/.Accessed September 1, 2008. 34. Conroy RM, Pyorale K, FitzGerald AP, et al; SCORE project group. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J. 2003;24:987-1003. 35. Assmann G, Cullen P, Schulte H. Simple scoring scheme for calculating the risk of acute coronary events based on the 10year follow-up of the prospective cardiovascular Munster (PROCAM) study. Circulation. 2002;105:310-315. 36. Grover SA, Paquet S, Levinton C, et al. Estimating the benefits of modifying risk factors of cardiovascular disease: a comparison of primary vs. secondary prevention. Arch Intern Med. 1998;158:655-662. 37. Lee ET, Howard BV,Wang W, et al Prediction of coronary heart disease in a population with high prevalence of diabetes and albuminuria: the Strong Heart Study. Circulation. 2006;113: 2897-2905. 38. Siyambalapitiya S, Bulugahapitiya U, Sithole J, et al. Combining population health and baseline risk strategy by determining an age cut off for initiating statins in patients with diabetes: a population-based study. Diabetes Care. 2007;30: 2025-2059.
Screening for the Presence of Coronary Artery Disease Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial draft of this chapter was prepared by Paul Poirier MD PhD FRCPC FACC FAHA KEY MESSAGES • Compared to people without diabetes, people with diabetes (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 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 and the 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, pharmacologic or nuclear stress imaging may be required. INTRODUCTION The majority (65 to 80%) of people with diabetes will die from heart disease (1,2). Compared to people without diabetes, people with diabetes (especially women) are at higher risk of developing heart disease, and at an earlier age. A high proportion of deaths occur in patients with no prior signs or symptoms of cardiovascular disease (CVD). Furthermore, people with diabetes have a high prevalence of silent myocardial ischemia, and almost one-third of myocardial infarctions (MIs) occur without recognized or typical symptoms (silent MIs) (3).The goals of screening are to improve life expectancy and quality of life by preventing MI and heart failure through the early detection of coronary artery disease (CAD). STRESS TESTING Exercise stress testing is useful in patients at high risk of CAD for the assessment of prognosis and the identification of individuals who may benefit from coronary artery revascularization to improve long-term survival. The most predictive clinical observation for CAD in the person with or without diabetes is a history of chest pain or discomfort, but these features will be absent in a significant number (20 to 50%) of people with diabetes (4-10). Clinical findings such as dyspnea on exertion, resting electrocardiogram (ECG) abnormalities or multiple risk factors for atherosclerosis may also indicate the presence of CAD. Recognition of such features is of clinical importance, as the outcome of CAD events is worse in people with diabetes when shortness of breath is the primary symptom (4). The presence of CAD risk factors and resting ECG abnormalities identify patients with diabetes at increased risk of important CAD and abnormal stress ECG or perfusion imaging results (11).A resting ECG at the time of diagnosis of diabetes also provides a baseline to which future ECGs can be compared. In patients considered to be at high risk for CAD, a repeat resting ECG may detect changes that result from silent MI and lead to earlier detection of critical CAD.There is evidence that early screening and intervention in people with diabetes and with silent ischemia is beneficial and may improve long-term survival (7,12). Screening with exercise ECG stress testing will find 3-vessel CAD in 13 to 15% of those with abnormal stress test findings (10,13) and lead to angiography with revascularization in 1 to 3% of asymptomatic individuals (10,13-15). The Definition of Ischemia in Asymptomatic Diabetes (DIAD) study (11) is prospectively investigating the value of routine adenosine stress myocardial perfusion scanning in asymptomatic patients with type 2 diabetes ≥55 years for the prevention of coronary events. The baseline study showed either perfusion defects or stressinduced ECG abnormalities in 22% of patients and large defects in 6%. In this study, multiple risk factors for CAD did not help to predict the patients with positive screening tests for CAD.Yet, a randomized pilot study on the impact of stress testing to screen for CAD in asymptomatic subjects with diabetes suggested a significant reduction in cardiac death and MI (16). Larger and adequately powered studies are necessary to support this provocative observation before clinical practice is changed. However, it is important to keep in mind that the goals of screening for CAD are to improve life expectancy and quality of life by preventing MI and heart failure through early detection. The choice of initial stress test should be based on evaluation of the resting ECG, the individual’s ability to exercise, and local expertise and technology. ECG abnormalities that limit the diagnostic accuracy of a stress ECG include resting ST depression (≥1 mm), left bundle branch block (LBBB) or right bundle branch block, an intraventricular conduction defect with a QRS duration >120 ms, ventricular paced S99 COMPLICATIONS AND COMORBIDITIES
Page 1:
Canadian Publication Mail Agreement
Page 4 and 5:
2008 CLINICAL PRACTICE GUIDELINES i
Page 6 and 7:
2008 CLINICAL PRACTICE GUIDELINES i
Page 8 and 9:
2008 CLINICAL PRACTICE GUIDELINES v
Page 10 and 11:
2008 CLINICAL PRACTICE GUIDELINES v
Page 12:
2008 CLINICAL PRACTICE GUIDELINES x
Page 16 and 17:
2008 CLINICAL PRACTICE GUIDELINES S
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63: 2008 CLINICAL PRACTICE GUIDELINES S
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
show all

2008 Clinical Practice Guidelines - Canadian Diabetes Association

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?