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Chapter 23 Paul Poirier, Robert Dufour , André Carpentier , Éric Larose

Canadian Diabetes Association Clinical Practice Guidelines Screening for the Presence of Coronary Artery Disease. Chapter 23 Paul Poirier, Robert Dufour , André Carpentier , Éric Larose . Screening for Coronary Artery Disease (CAD) Checklist. 2013.

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Chapter 23 Paul Poirier, Robert Dufour , André Carpentier , Éric Larose

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

  2. Screening for Coronary Artery Disease (CAD) Checklist 2013 • 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

  3. MI at a Younger Age Among Those with Diabetes Diabetes n = 379,003 No Diabetes n = 9,018,082 Database 1994-2000 Diabetes Men Women 3.0 2.5 2.0 No diabetes Men Women 1.5 No. events per 100 person- years 1.0 0.5 0 MI = myocardial infarction Age group All lines fitted according to a polynomial equation; R2= 0.99–1.00 for each Booth GL, et al. Lancet 2006;368:29-36.

  4. Who Should be Screened with ECG? 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

  5. Who Should have Stress Testing and/or Functional Imaging to Screen for CAD? • Typical or atypical cardiac symptoms • Associated diseases: • PAD • Carotid bruits • TIA • Stroke • Resting ECG abnormalities (e.g. Q waves) Exercise ECG stress testing • If cannot exercise or resting ECG abnormality present: • Pharmacologic stress echo • Pharmacologic stress nuclear imaging

  6. Who Needs a Referral to a Cardiac Specialist? • Demonstrate ischemia at low exercise capacity on stress testing • <5 metabolic equivalents (METs)

  7. Recommendations 1 and 2 • 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 • A repeat resting ECG should be performed every 2 years in patients with diabetes. [Grade D, Consensus]

  8. Recommendation 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 associateddiseases • 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]

  9. Recommendation 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]

  10. Recommendation 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]

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

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