Begin 1 Year 6 Years

□ Intervention Control

FIGURE 4 Change in body mass index in patients participating in a multirisk factor intervention trial. Initial weight loss of nearly 10% at one year in the intervention group is slowly eroded overtime; at 6years the body mass index tends to be higher as compared to beginning with a gain of 4% (p:n.s.). In the control group there is a significant increase in body mass index by 8% (p< 05). Source: From Ref. 55.

The following recommendations have been modified from the Health Professional's Guide to Diabetes and Exercise. A graded treadmill exercise test should be performed in all patients in order to detect myocardial ischemia, and to determine the individual cardiopulmonary fitness and exercise tolerance. The optimal training heart rate is determined as 80% of the maximal symptom free heart rate. In patients with questionable results alternative stress tests (stress echocardiography, radionuclide stress test) can be employed to increase the diagnostic precision. In patients with typical anginal symptoms or significant ST-segment changes invasive diagnostic coronary angiography is indicated. Patients with hemodynamically significant coronary lesions should undergo either interventional or surgical treatment as indicated prior to embarking on an exercise program.

Long-standing diabetes may result in significant impairment of myocardial function and cause symptoms and signs of congestive heart failure (diabetic cardiomyopathy) (35, 41). Myocardial hypertrophy combined with an increase in interstitial fibrosis may cause diastolic heart failure, indistinguishable from systolic heart failure on clinical grounds. Echocardiography is used to assess left ventricular performance, rule out valvular heart disease and determine left ventricular compliance in patients with myocardial hypertrophy. The magnitude of left ventricular hypertrophy is correlated to the degree and duration of hyperinsulinemia, whereas the degree of left ventricular dysfunction seems to be mainly the result of hyperglycemia.

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