Approach

Presence of risk factors

For prevention and management of both atherosclerotic cardiovascular disease (CVD) and heart failure, cardiovascular (CV) risk factors should be systematically assessed at least annually in all people with diabetes. These risk factors include duration of diabetes, obesity/overweight, hypertension, dyslipidaemia, smoking, a family history of premature coronary disease, chronic kidney disease (CKD), and the presence of albuminuria.[2][30]

Female sex and elevated C-reactive protein levels confer additional CVD risk.[78][79][82][93]

The American College of Cardiology/American Heart Association atherosclerotic CVD risk calculator should be used to aid with overall CVD risk assessment and the 10-year risk for first CVD event. AHA/ACC: ASCVD risk calculator Opens in new window A European equivalent, known as SCORE2-Diabetes, is recommended by the European Society of Cardiology for use in people aged 40 to 69 years with type 2 diabetes.[7]

Symptoms

Symptoms specific to CVD should be elicited in the history.

Coronary artery disease (CAD)

  • Chest discomfort (may be absent in 20% to 30% of patients with diabetes, often called 'silent ischaemia')[20]

  • Dyspnoea on exertion; diaphoresis; nausea.

Cerebrovascular disease

  • Numbness; tingling; headache; hemiparesis; aphasia.

Peripheral arterial disease (PAD)

  • Most patients with PAD are asymptomatic. Intermittent claudication occurs in only 33% to 50% of patients.[140] Claudication presents as aching, burning, cramping, discomfort, or fatigue in the buttock, thigh, calf, or ankle on exertion. Symptoms occur consistently during walking, increase with progressive exercise intensity, and are quickly relieved by rest (usually within 10 minutes).[29]

  • Rest pain in severe disease; often affects the forefoot and is worsened with limb elevation and relieved by dependency.[29]

  • Other non-joint-related exertional lower extremity symptoms (not typical of claudication) or symptoms of impaired walking function: may include leg muscle discomfort associated with walking that requires >10 minutes of rest to resolve, or leg weakness/numbness/fatigue during walking without pain.[29]

  • Erectile dysfunction.[29]

  • History of non-healing or slow-healing lower extremity wound.[29]

Heart failure

  • Dyspnoea; persistent cough; ankle oedema; fatigue.

Physical findings

Hypertension

  • In patients with diabetes, blood pressure (BP) ≥130/80 mmHg confirmed using ≥2 measurements obtained on ≥2 occasions.[30]

  • Patients with diabetic CVD may also be diagnosed with hypertension if BP ≥180/110 mmHg is recorded at a single visit.[30]

Acute myocardial infarction (MI) or congestive heart failure

  • Rales; hypotension; peripheral oedema; tachycardia; S3 gallop; jugular venous distention.

Cerebrovascular accident

  • Aphasia; hemisensory loss; cranial nerve palsies; hemiparesis.

PAD

  • Decreased or absent lower extremity pulses (femoral, popliteal, dorsalis pedis, or posterior tibial arteries); bruit over narrowed artery (e.g., epigastric, periumbilical, groin); hair loss; smooth, shiny skin; non-healing lower extremity ulcers and necrosis; nail bed changes; calf muscle atrophy; elevation pallor/dependent rubor.[29]

Investigations

  • All patients should have a baseline lipid profile and this should be repeated regularly.[30]

  • C-reactive protein is not a routine test but may be useful for risk stratification.[82][83][84]

  • Haemoglobin A1c (HbA1c) is used to monitor glycaemic control.[30]

Suspected CAD and/or heart failure

In asymptomatic individuals, routine screening for CAD is not recommended as it does not improve outcomes as long as risk factors for atherosclerotic CVD are treated.[30] However, measurement of B-type natriuretic peptide (BNP) or N-terminal prohormone B-type natriuretic peptide (NT-proBNP) on at least a yearly basis should be considered to screen asymptomatic adults with diabetes for heart failure.[30][141] This is because adults with diabetes are at increased risk for the development of asymptomatic cardiac structural or functional abnormalities (stage B heart failure) or symptomatic (stage C) heart failure.[30] If abnormal natriuretic peptide levels are detected, echocardiography is recommended. Identification, risk stratification, and early treatment of risk factors in people with diabetes and asymptomatic stages of heart failure reduce the risk for progression to symptomatic heart failure.[30]

All patients with symptoms or signs suggestive of CAD should have a resting 12-lead ECG. A chest x-ray (CXR) is not a routine test but may be useful to assess heart size and pulmonary congestion and evaluate for alternative causes of dyspnoea. The sensitivity of CXR for making a diagnosis is poor. For example, 1 in 5 individuals with acute heart failure has no signs of congestion on a CXR.[141]

Diagnostic cardiac testing should be considered in those with: 1) typical or atypical cardiac symptoms; and 2) an abnormal resting ECG.

  • Transthoracic doppler echocardiogram (echo): two-dimensional echo with Doppler assessment at rest is a key diagnostic test in the evaluation of chest pain or shortness of breath as well as establishing the initial diagnosis and cause of clinical heart failure.[141] Visualisation of left and right ventricular function and regional wall motion abnormalities allows for the assessment of CAD risk and may help to guide clinical decision-making. Performance of echo at the bedside is ideal for patients with acute chest pain and can be done using point-of-care or handheld devices in institutions where such capabilities are available.[30]

  • Exercise ECG: often used as an initial test. Can be used without or with echocardiographic imaging.[30] It is suitable for patients, who can exercise and who have a resting ECG that is interpretable for ST-segment shifts.[142][143] Symptom-limited exercise ECG involves graded exercise until physical fatigue, limiting chest pain, marked ischaemia, or a drop in blood pressure occurs. Candidates for exercise ECG are those: a) without disabling comorbidity (e.g., frailty, marked obesity [body mass index >40 kg/m²], PAD, chronic obstructive pulmonary disease, or orthopaedic limitations) and capable of performing exercise safely; and b) without ST-T abnormalities on resting ECG (e.g., >0.5 mm ST depression, left ventricular hypertrophy, paced rhythm, left bundle branch block, Wolff-Parkinson-White pattern, or digoxin use).[143] There is a paucity of data on the predictive power of exercise testing in patients with diabetes, but available data suggest that ischaemic findings on exercise ECG are predictive of prognosis.[144] In a study of 1282 patients (15% with diabetes), sensitivity (47% vs. 52%), and specificity (81% vs. 80%) for exercise treadmill testing were similar in people with and without diabetes.[145]

  • Pharmacological stress testing: patients who have resting ECG abnormalities that preclude exercise stress testing or those unable to exercise should undergo pharmacological stress echo or nuclear imaging.[30][142][143] Stress echo can be used to define ischaemia severity and for risk stratification purposes. Nuclear imaging (positron emission tomography [PET] or single-photon emission computed tomography [SPECT] myocardial perfusion imaging) enables detection of perfusion abnormalities, measurement of left ventricular function, and detection of high-risk findings, such as transient ischaemic dilation.[143]

  • Cardiac magnetic resonance imaging (MRI), or stress cardiac MRI (if available), may be useful in select patients with diabetes with multi-vessel disease and severe left ventricular dysfunction.[146] These tests have the capability to accurately assess global and regional left and right ventricular function, detect and localise myocardial ischaemia and infarction, and determine myocardial viability, without the need for radiation.[143][146] They can also detect myocardial oedema and microvascular obstruction, which can help differentiate acute versus chronic myocardial infarction, as well as other causes of acute chest pain, including myocarditis.[143]

  • Computed tomography (CT) scan for coronary artery calcium (CAC): several studies have shown that using ≥16-slice CT scanners, CAC score >400 is associated with high likelihood of inducible myocardial ischaemia and should prompt further testing.[147] In patients with pre-test likelihood of CAD <50%, a CAC score of 0 provides very strong evidence against the presence of CAD, with a high degree of certainty.[148]

  • CT coronary angiography (CTA): ≥16-slice CT scanners have 90% sensitivity and 90% specificity for >50% diameter stenosis, which is the minimum criterion for consideration of revascularisation.[148] CTA may be useful for patients with equivocal myocardial perfusion scanning; those with possible left main or triple-vessel CAD; patients with cardiomyopathy unrelated to CAD; and young patients undergoing valvular surgery.[148] Screening for asymptomatic obstructive CAD among patients with type 1 diabetes and patients with type 2 diabetes using CTA is not beneficial.[149]

  • Invasive coronary angiography: usually reserved for patients with acute coronary syndrome, frequent angina, high-risk and/or high pretest probability of CAD that requires surgical or percutaneous intervention, and/or high-risk findings on stress testing.[143]

Suspected cerebrovascular accident

  • CT or MRI of the head and duplex ultrasonography of carotids if indicated by symptoms.

Suspected PAD

  • Joint American Heart Association and American College of Cardiology guidelines recommend that all patients with history or physical examination findings suggestive of PAD should have a resting ankle-brachial index (ABI), with or without ankle pulse volume recordings and/or Doppler waveforms.[29] Screening with resting ABI is also considered reasonable in patients with any of the following characteristics: age ≥65 years or older; age 50 to 64 years with risk factors for atherosclerosis (e.g., diabetes, smoking history, dyslipidaemia, hypertension), CKD, or family history of PAD; age <50 years with diabetes and one additional risk factor for atherosclerosis; patients with known atherosclerotic disease in another vascular bed (e.g., coronary, carotid, subclavian, renal, mesenteric artery stenosis, or abdominal aortic aneurysm).​[29] The American Diabetes Association recommends screening for PAD using ABI in asymptomatic people with any of the following characteristics: age ≥50 years; diabetes with duration ≥10 years; comorbid microvascular disease; clinical evidence of foot complications; or any end-organ damage from diabetes.[30]

  • ABI of 1.0 to 1.4 is normal. ABI of ≤0.9 indicates the presence of PAD in the legs. ABI of 0.91 to 0.99 is borderline.[29]

  • ABI may not be accurate in patients with non-compressible arteries, such as those with long-standing diabetes mellitus or CKD, particularly those on dialysis. Diagnosis of PAD should not be excluded based on normal or raised ankle brachial pressure index alone in people with diabetes or CKD.[29] See Peripheral arterial disease.

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