2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S100 rhythm or pre-excitation. Individuals with these resting ECG findings should have a stress test with an imaging modality such as scintigraphic myocardial perfusion imaging or echocardiography. The strongest and most consistent prognostic marker identified during exercise ECG stress testing is the person’s maximum exercise capacity (4). Although exercise capacity is decreased in individuals with diabetes (17,18), it is still of prognostic importance (4). Silent ischemia is most likely to occur in individuals with diabetes who are older (mean age 65 years) and have elevated total cholesterol and proteinuria (14). An ECG with ST-T abnormalities at rest has been shown to be most predictive for silent ischemia (OR 9.27, 95% CI, 4.44-19.38) and the only significant predictor of silent ischemia in women (14).The relevance of ST-T abnormalities as a predictive factor for silent ischemia emphasizes the importance of recording a resting ECG in most individuals with type 2 diabetes.An abnormal ECG may indicate the need for further investigations and result in the earlier detection and treatment of CAD (14).An abnormal exercise ECG is associated with an annual CAD event rate of 2.1%, compared with 0.97% in subjects with normal exercise ECG (15). Myocardial ischemia (whether silent or symptomatic) detected during exercise stress testing in individuals with diabetes is associated with poorer long-term survival compared to individuals without diabetes (7). Silent MI is common (40%) in older asymptomatic people with type 2 diabetes, but is more frequent (65%) in those with diabetes who also have microalbuminuria (19). People with diabetes and silent ischemia have an annual event rate for CAD of 6.2% (50% of events were new-onset angina and 50% cardiac death or MIs) (20). Thus, silent MI is a prelude not only to symptomatic ischemia, but also to potentially fatal events.Also, it has been shown in a randomized trial in patients with silent ischemia (the vast majority of whom did not have diabetes) that longterm anti-ischemic drug therapy (~11 years follow-up) reduces cardiac events (cardiac death, nonfatal MI, acute coronary syndrome or revascularization) with preservation of ejection fraction (21). 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 in this population. Individuals who cannot adequately exercise on a stress test have a poorer prognosis than those who can, regardless of the reason for this incapacity. Perfusion imaging also provides important prognostic information. Myocardial perfusion imaging has similar predictive value for cardiac death and nonfatal MI in individuals with diabetes as in those without diabetes (22). For those unable to perform an exercise ECG stress test, pharmacologic stress imaging using dipyridamole, adenosine or dobutamine testing is required. Stress echocardiography and stress nuclear imaging have similar values for cardiac events in the general population (23), but no comparative data are available for the person with diabetes. In a meta-analysis of perfusion imaging, an abnormal scan was predictive of future CAD events in subjects with and without diabetes. However, the cardiac event rate in individuals with diabetes was significantly greater than in those without diabetes (22). The choice of the optimal imaging modality to detect stressinduced MI is best determined by local availability and expertise. The utility of newer CAD diagnostic modalities such as computed tomography angiography, coronary artery calcium scoring and cardiac magnetic resonance imaging is currently unknown in terms of guiding management decisions in patients with type 2 diabetes (24). RECOMMENDATIONS 1. In the following individuals, in addition to CAD risk assessment, a baseline resting ECG should be performed [Grade D, Consensus] in: • All individuals >40 years of age • All individuals with duration of diabetes >15 years • All individuals (regardless of age) with hypertension, proteinuria, reduced pulses or vascular bruits A repeat resting ECG should be performed every 2 years in people considered at high risk for CV events [Grade D, Consensus]. 2. Persons 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 (4)] • Resting abnormalities on ECG (e.g. Q waves) [Grade D, Consensus] • Peripheral arterial disease (abnormal ankle-brachial ratio) [Grade D, Level 4 (9)] • Carotid bruits [Grade D, Consensus] • Transient ischemic attack [Grade D, Consensus] • Stroke [Grade D, Consensus] 3. Pharmacologic 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. LBBB or ST-T abnormalities) [Grade D, Consensus]. In addition, individuals who require stress testing and are unable to exercise should undergo pharmacologic stress echocardiography or nuclear imaging [Grade C, Level 3 (22)]. 4. Individuals with diabetes who demonstrate ischemia at low exercise capacity (
Management of Acute Coronary Syndromes, p. S119 Treatment of Diabetes in People With Heart Failure, p. S123 REFERENCES 1. Lee WL, Cheung AM, Cape D, et al. Impact of diabetes on coronary artery disease in women and men: a meta-analysis of prospective studies. Diabetes Care. 2000;23:962-968. 2. Booth GL, Kapral MK, Fung K, et al. Relation between age and cardiovascular disease in men and women with diabetes compared with non-diabetic people: a population-based retrospective cohort study. Lancet. 2006;368:29-36. 3. Cohn PF, Fox KM, Daly C. Silent myocardial ischemia. Circulation. 2003;108:1263-1277. 4. 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;25:543-550. 5. Rajagopalan N, Miller TD, Hodge DO, et al. Identifying highrisk asymptomatic diabetic patients who are candidates for screening stress single-photon emission computed tomography imaging. J Am Coll Cardiol. 2005;45:43-49. 6. Weiner DA, Ryan TJ, Parsons L, et al. Significance of silent myocardial ischemia during exercise testing in patients with diabetes mellitus: a report from the Coronary Artery Surgery Study (CASS) Registry. Am J Cardiol. 1991;68:729-734. 7. Inoguchi T,Yamashita T, Umeda F, et al. High incidence of silent myocardial ischemia in elderly patients with non insulindependent diabetes mellitus. Diabetes Res Clin Pract. 2000;47: 37-44. 8. Nesto RW, Phillips RT, Kett KG, et al. Angina and exertional myocardial ischemia in diabetic and nondiabetic patients: assessment by exercise thallium scintigraphy. Ann Intern Med. 1988;108:170-175. 9. 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;147:649-654. 10. 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. 11. Myers J, Prakash M, Froelicher V, et al. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med. 2002;346:793-801. 12. Sorajja P, Chareonthaitawee P, Rajagopalan N, et al. Improved survival in asymptomatic diabetic patients with high-risk SPECT imaging treated with coronary artery bypass grafting. Circulation. 2005;112(9 suppl):I311-I316. 13. Paillole C, Ruiz J, Juliard JM, et al. Detection of coronary artery disease in diabetic patients. Diabetologia. 1995;38:726-731. 14. Prevalence of unrecognized silent myocardial ischemia and its association with atherosclerotic risk factors in noninsulindependent diabetes mellitus. Milan Study on Atherosclerosis and Diabetes (MiSAD) Group. Am J Cardiol. 1997;79:134-139. 15. Faglia E, Favales F, Calia P, et al; Milan Study on Atherosclerosis and Diabetes (MiSAD). Cardiac events in 735 type 2 diabetic patients who underwent screening for unknown asymptomatic coronary heart disease: 5-year follow-up report from the Milan Study on Atherosclerosis and Diabetes (MiSAD). Diabetes Care. 2002;25:2032-2036. 16. Faglia E, Manuela M,Antonella Q, et al. Risk reduction of cardiac events by screening of unknown asymptomatic coronary artery disease in subjects with type 2 diabetes mellitus at high cardiovascular risk: an open-label randomized pilot study. Am Heart J. 2005;149:e1-e6. 17. Poirier P, Garneau C, Bogaty P, et al. Impact of left ventricular diastolic dysfunction on maximal treadmill performance in normotensive subjects with well-controlled type 2 diabetes mellitus. Am J Cardiol. 2000;85:473-477. 18. Poirier P, Bogaty P, Garneau C, et al. Diastolic dysfunction in normotensive men with well-controlled type 2 diabetes: importance of maneuvers in echocardiographic screening for preclinical diabetic cardiomyopathy. Diabetes Care. 2001;24:5-10. 19. Rutter MK, McComb JM, Brady S, et al. Silent myocardial ischemia and microalbuminuria in asymptomatic subjects with non-insulin-dependent diabetes mellitus. Am J Cardiol. 1999; 83:27-31. 20. Rutter MK, Wahid ST, McComb JM, et al. Significance of silent ischemia and microalbuminuria in predicting coronary events in asymptomatic patients with type 2 diabetes. J Am Coll Cardiol. 2002;40:56-61. 21. Erne P, Schoenenberger AW, Zuber M, et al, Effects of antiischaemic drug therapy in silent myocardial ischaemia type 1: the Swiss Interventional Study on Silent Ischaemia type 1 (SWISSI I): a randomized, controlled pilot study. Eur Heart J 2007;28:2110-2117. 22. Shaw LJ, Iskandrian AE. Prognostic value of gated myocardial perfusion SPECT. J Nucl Cardiol. 2004;11:171-185. 23. Schinkel AF, Bax JJ, Elhendy A, et al. Long-term prognostic value of dobutamine stress echocardiography compared with myocardial perfusion scanning in patients unable to perform exercise tests. Am J Med. 2004;117:1-9. 24. Bax JJ,Young LH, Frye RL, et al. Screening for coronary artery disease in patients with diabetes. Diabetes Care. 2007;30:2729- 2736. S101 COMPLICATIONS AND COMORBIDITIES
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