Ischaemic heart disease

Ischaemic heart disease is arguably the most important complication of diabetes. It is certainly the leading cause of premature mortality amongst people with T2DM and cardiovascular risk modification is one of the most important goals of diabetes treatment.

How long has the patient had diabetes?

Ischaemic heart disease is typically a relatively late complication of T1DM but in T2DM it can even be a presenting symptom or can antedate the onset of diabetes.

Is there any chest pain?

Typical cardiac ischaemic pain presents as a central crushing or 'band-like' pain around the anterior chest with radiation to the arm, jaw or back.

However, any chest pain in someone with diabetes merits consideration as potential cardiac ischaemia, especially if exercise-related. Silent ischaemia (i.e. no chest pain) is said to be typical in diabetes and thus presentations such as unexplained dyspnea, collapse, sweatiness without apparent cause should also be considered as potential symptoms of cardiac ischaemia.

Are there additional risk factors?

The presence of smoking, hypercholesterolaemia, hypertension and a strong family history of premature ischaemic heart disease should all be enquired about.

Is there any past history of myocardial infarction or acute coronary syndrome?

Previous episodes of MI, acute coronary syndrome, percutaneous interventions or coronary venous grafting further increases the likelihood of subsequent presentations due to ischaemic heart disease.

Does the patient have othopnoea, paroxysmal nocturnal dyspnoea, ankle swelling or exertional dyspnoea?

Symptomatic heart failure is highly likely to be due to ischaemic heart disease even if the patient is not aware of having previous episodes of angina and/or myocardial infarction.

Is there a past medical history of stroke, TIA, intermittent claudication, rest pain or lower limb ulceration/gangrene?

Evidence of vascular disease elsewhere in the arterial tree makes it highly likely that the patient will also have coronary disease.

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