canadian diabetes association clinical practice guidelines screening for the presence of coronary...

Canadian Diabetes Association Clinical Practice Guidelines

Screening for the Presence of Coronary Artery Disease

Chapter 23

Paul Poirier, Robert Dufour,

André Carpentier, Éric Larose

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

Screening for Coronary Artery Disease (CAD) Checklist

SCREEN with baseline resting ECG in select patients

STRESS TESTING for patients with symptoms or other associated diseases

REFER patients with inducible ischaemia to a cardiac specialist

2013


20-30 31-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85

MI at a Younger Age Among Those with Diabetes

Age group

0.5

1.0

1.5

2.0

2.5

3.0

0No

. ev

ents

per

100

per

so

n-

year

s

Booth GL, et al. Lancet 2006;368:29-36.

All lines fitted according to a polynomial equation; R2= 0.99–1.00 for each

MI = myocardial infarction

Diabetes n = 379,003 No Diabetes n = 9,018,082 Database 1994-2000

No diabetesMen

Women

DiabetesMen

Women


Age >40 years

Duration of DM >15years +

Age >30 years

End organ damage– Microvascular– Macrovascular

Cardiac risk factors

Baseline resting

ECG

Repeat every 2 years

Who Should be Screened with ECG?


Exercise ECG stress testing

If cannot exercise or resting ECG abnormality present:– Pharmacologic stress

echo– Pharmacologic stress

nuclear imaging

Typical or atypical cardiac symptoms

Associated diseases:– PAD– Carotid bruits– TIA– Stroke

Resting ECG abnormalities (e.g. Q waves)

Who Should have Stress Testing and/or Functional Imaging to Screen for CAD?


Who Needs a Referral to a Cardiac Specialist?

• Demonstrate ischemia at low exercise capacity on stress testing– <5 metabolic equivalents (METs)


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. A repeat resting ECG should be performed every 2

years in patients with diabetes. [Grade D, Consensus]

Recommendations 1 and 2


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] – Signs or symptoms of associated diseases

• Peripheral arterial disease (abnormal ankle-brachial index) [Grade D, Level 4]

• 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]

Recommendation 3


4. 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

(eg. 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]

Recommendation 4


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]

Recommendation 5

CDA Clinical Practice Guidelines

www.guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

www.diabetes.ca – for patients

http://guidelines.diabetes.ca/

http://diabetes.ca/

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