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6 Management of coronary artery

disease and diabetes

6.1 Chronic coronary syndromes and

diabetes 6.1.1. Clinical presentation Diabetes is a well-established risk factor for ischaemic heart disease (IHD), and CAD accounts for 40−80% of deaths in patients with T2DM.148,359,381 In patients with CCS, T2DM is also associated with an increased risk of the combined outcome (CV death, MI, or stroke) with an adjusted HR of 1.28.39 Studies show that clinical symptoms of CAD in patients with diabetes are often less severe and atypical in presentation. In the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial in patients with angiographically confirmed CAD and a mean diabetes duration of 10.4 years, typical angina, anginal equivalent, or a combination of both were observed in 19%, 21%, and 42% of patients, respectively, whereas 18% remained asymptomatic.382,383 In 510 asymptomatic patients with diabetes without prior CVD, computed tomography (CT) revealed calcifications indicating the presence of coronary atherosclerosis in 46% of patients.384 An even higher prevalence of CAD was found in an autopsy study of asymptomatic decedents with diabetes.385

6.1.2 Screening and diagnosis

For details about sensitivity, specificity, and pre-test probability of each procedure in the assessment of CHD, we refer to the 2019 ESC Guideline on chronic coronary syndromes.299 Screening for asymptomatic CAD in diabetes remains controversial. Various RCTs evaluating the impact of routine screening for CAD in asymptomatic patients with diabetes and no history of CAD showed

Global CV risk and disease assessment

Obesity Nutritiona Inactivity Smoking

Assessment of lifestyle risk factor components

Body weight Body composition Questionnaire Questionnaire Exercise testing Questionnaire

General lifestyle recommendations

Adaption of lifestyle recommendations to comorbidities, age, frailty, sex, patient preference

Individualized multidisciplinary lifestyle intervention programme

Step 2

Step 1

HFpEF HFrEF AF CAD PAD

Figure 13 Assessment of lifestyle risk-factor components and stepwise lifestyle recommendations in patients with diabetes. AF, atrial fibrillation; CAD, coronary artery disease; CV, cardiovascular; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; PAD, peripheral arterial diseases. aNutrition includes components on quality and quantity of nutritional components, as well as alcohol consumption.

ESC Guidelines                                                                                                                                                                                          4083

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