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.

HbA1c

An essential baseline when considering any diabetes complication.

Fasting lipids

A full fasting lipid profile including total and HDL cholesterol, LDL cholesterol and triglycerides is an important first step to managing cardiovascular risk in diabetes.

U+Es

An essential baseline when considering any diabetes complication. It may also alert the physician to the potential presence of reno-vascular disease.

ECG

An ECG should be performed if there is the slightest suspicion of ischaemic heart disease as it can be asymptomatic. In some clinics ECGs are performed routinely on all new patients as part of baseline assessment.

Cardiac enzymes

CK and troponin should only be assessed in the context of an appropriate clinical presentation, but if there is suspicion that the patient has had an episode of coronary ischaemia within the previous 24 hours then these tests should be requested. In the absence of an appropriate clinical presentation they are not indicated and may be very misleading as other conditions such as statin induced myositis and renal impairment can induce elevations of CK and troponin respectively.

Exercise test

If there is a history of exertional chest pain then an exercise test is still a very useful test to a) confirm the cardiac origin of the symptom and b) risk stratify the patient for urgent or non-urgent angiography. However, in practice, if there is suspicion that the patient has coronary disease then a referral to the cardiologists, who undertake further investigation according to local protocols, is usually the best course of action.

Angiography

Coronary angiography is the definitive investigation for ischaemic heart disease and will allow the cardiologists to decide if medical, percutaneous or surgical intervention is the best course of action.

Myocardial perfusion scanning or stress echo

These are sometimes performed as an alternative to exercise testing where the patient will find using a treadmill difficult (eg previous lower limb amputation) or where the results of exercise testing are equivocal.

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