It is well known that patients with diabetes are at increased risk for cardiac events, but I am unclear as to what warrants a workup for cardiac disease in this population (e.g., a cardiac stress test) except in instances where patients report such symptoms as angina or dyspnea.

Given that people with diabetes have different symptoms or may have no symptoms at all, would a more aggressive approach in working up this population be advisable?—MARY HORST, ANP, Goodview, Va.

Concerns about the high rate of cardiovascular disease in the diabetes population are well warranted since the risks for MI and stroke are two to four times greater among these patients. However, a large observational randomized clinical trial noted no differences in cardiac events over 4.8 years in those screened with adenosine-stress radionuclide myocardial perfusion imaging (MPI) over those randomized to routine care (JAMA. 2009;301:1547-1555; available at jama.jamanetwork.com/article.aspx?articleid=183751, accessed February 15, 2014). 

Earlier trials had also verified the lack of benefit to screening asymptomatic patients. This evidence has led the American Diabetes Association to advise against routine screening in favor of aggressive risk modification, including antiplatelet therapy as indicated, smoking cessation, and aggressive BP and lipid management.

It is important to assess for such other subtle clues as unusual fatigue or shortness of breath or for other signs of vascular disease. For instance, the presence of erectile dysfunction in patients with type 2 diabetes has been shown to correlate with coronary heart disease (J Am Coll Cardiol. 2008;51:2045-2050).

Other complications of diabetes, including retinopathy and nephropathy, share the same pathophysiologic mechanism for peripheral vascular disease, so a careful review of history is warranted when assessing risk.—Katherine Pereira, DNP, RN, FNP-BC, ADM-BC, coordinator, FNP specialty, Duke University School of Nursing, Durham, N.C. (185-2)


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