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Dr Dayasagar Rao V, Hyderabad 04 January 2018

Degree of atherosclerosis in diabetic patients is more extensive with accelerated progression in poorly-controlled diabetes.
Do all asymptomatic patients with DM need CV investigations? No. Only patients with following characteristics should be investigated further: Age >40 years; DM >10 years; more number of associated CV risk factors, in addition to DM (HT, hyperlipidemia, strong f/h/o premature CAD, smoker); DM with co-existent vascular disease in other territories (PAD, H/o stroke/carotid bruit, microalbuminuria).
Should all patients suspected of CAD undergo coronary angiogram? No. Stepwise approach is desirable starting with; resting EKG (pathological Q waves), TMT - positive at low workload <5 METS, CAC score >400 AU, if high probability of CAD is present, stress MPI should be done. In those with high risk perfusion defect, area of perfusion defect >10% of LV, perfusion defects in multiple vascular territories, E/O stress-induced LV dysfunction.
Those with high risk perfusion defects should be subjected to invasive coronary angiogram in asymptomatic patients with diabetes.

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