1. Canadian Diabetes Association Clinical Practice Guidelines Screening for the Presence of Coronary Artery Disease Chapter 23 Paul Poirier, Robert Dufour, André Carpentier, Éric Larose

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 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

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association MI at a Younger Age Among Those with Diabetes Age group 0.5 1.0 1.5 2.0 2.5 3.0 0 No. events per 100 person- years Booth GL, et al. Lancet 2006;368:29-36. All lines fitted according to a polynomial equation; R 2 = 0.99–1.00 for each MI = myocardial infarction Diabetes n = 379,003 No Diabetes n = 9,018,082 Database 1994-2000 No diabetes Men Women Diabetes Men Women

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

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

6. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Who Needs a Referral to a Cardiac Specialist? Demonstrate ischemia at low exercise capacity on stress testing – <5 metabolic equivalents (METs)

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

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

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

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

11. CDA Clinical Practice Guidelines www.guidelines.diabetes.cawww.guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) www.diabetes.ca www.diabetes.ca – for patients