Assessment of cardiovascular risk in diabetes: Risk scores and provocative testing

Abstract

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among patients with diabetes mellitus, who have a risk of cardiovascular mortality two to four times that of people without diabetes. An individualised approach to cardiovascular risk estimation and management is needed. Over the past decades, many risk scores have been developed to predict CVD. However, few have been externally validated in a diabetic population and limited studies have examined the impact of applying a prediction model in clinical practice. Currently, guidelines are focused on testing for CVD in symptomatic patients. Atypical symptoms or silent ischemia are more common in the diabetic population, and with additional markers of vascular disease such as erectile dysfunction and autonomic neuropathy, these guidelines can be difficult to interpret. We propose an algorithm incorporating cardiovascular risk scores in combination with typical and atypical signs and symptoms to alert clinicians to consider further investigation with provocative testing. The modalities for investigation of CVD are discussed.

Keywords: Atypical symptoms; Cardiovascular risk; Diabetes; Provocative testing; Risk scores; Silent ischaemia.

Figure 1

Suggested algorithm for investigation of cardiovascular disease in patients with diabetes. Since a 12-lead ECG is a safe and cheap test, it should be performed in people with diabetes with a low threshold. At each layer of testing, if the test is normal or unchanged from previous testing, consider whether the next level of testing is needed. ECG: Echocardiogram; LBBB: Left bundle branch block; CTCA: CT coronary angiogram; UKPDS: United Kingdom prospective diabetes study.