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V Routine foilow-up m Close follow-up

Vv'V Imaging

MM Cardiology referral/possible catheterization

V Routine foilow-up m Close follow-up

Vv'V Imaging

MM Cardiology referral/possible catheterization

FIGURE 2 Appropriate follow-up after screening exercise treadmill test (ETT). When initial exercise stress testing is done in asymptomatic diabetic patients, the type of follow-up depends on the pretest risk and the degree of abnormality on the stress test. Normal follow-up indicates annual reevaluation of symptoms and signs of CHD and ECG. A repeat ETT should be considered in 3-5 years if clinical status is unchanged. Close follow-up means shorter intervals between evaluation and follow-up ETT, i.e., 1-2 years. Pretest risk is assigned based on the presence of other vascular disease and risk factors. Source: Reprinted from Ref. 209.

On the other hand, a negative exercise electrocardiographic test at a high workload provides reassurance that the likelihood of advanced coronary artery disease is extremely low. It is important to interpret the findings of stress testing in light of the clinical pre-test probability of disease, as well as the extent of disease found on testing. The maximal value of stress testing is seen in those patients with an intermediate pre-test suspicion for disease.

A positive exercise electrocardiographic test should prompt either repetition with perfusion imaging or direct cardiac catheterization if the patient has high-risk clinical features, such as hypotension, bradycardia, ventricular dysrhythmmias or pulmonary edema, on the initial test. Patients should also be referred directly for cardiac catheterization if ischemia is induced by low-level exercise (<4 METs or heart rate <100 BPM or <70% age predicted) and manifested by one or more of the following:

1. Horizontal or downsloping ST depression >0.1 mV.

2. ST-segment elevation >0.1 mV in a noninfarct lead.

3. Five or more abnormal leads.

4. Persistent ischemic response >3 min after exertion, and

5. Typical angina (128)

Patients with moderate or large perfusion defects on imaging, or defects representative of multiple vascular territories, should be referral for cardiac catheterization in almost all circumstances. The identification of left main coronary disease, proximal left anterior descending artery disease, and multi-vessel disease is especially important, given the proven benefits of revascularization in diabetic patients with severe anatomy (27,115).

Conversely, in a patient with low suspicion for disease and relatively small, distal perfusion defects suggestive of distal coronary artery disease, it is often reasonable to manage the patient medically and follow-up closely.

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