What is the best approach to screen for and manage cardiovascular risk in a patient with potential risk factors for diabetes and cardiovascular disease?

Cardiovascular Risk Factor Screening in Patients with Diabetes

In patients with diabetes or at risk for diabetes, obtain a comprehensive metabolic risk panel including lipids (total cholesterol, LDL-C, HDL-C, triglycerides, and lipoprotein(a)), HbA1c, fasting glucose, serum creatinine with eGFR calculation, and urine albumin-to-creatinine ratio annually. 1, 2

Essential Laboratory Screening Panel

Lipid Assessment

• Measure total cholesterol, LDL-cholesterol, HDL-cholesterol, and triglycerides as the primary lipid assessment 1, 2
• Obtain lipoprotein(a) measurement at least once in a lifetime, as it is an independent risk factor for atherosclerotic disease that remains stable over time 1, 2

Glucose Metabolism Evaluation

• Measure both HbA1c and fasting plasma glucose in all patients with suspected or known cardiovascular disease 1
• HbA1c integrates average glycemic control over several months and helps predict cardiovascular risk 2
• In patients aged 40-70 years with overweight or obesity, screen for abnormal blood glucose as part of cardiovascular risk assessment 1

Renal Function Assessment

• Measure serum creatinine and calculate estimated glomerular filtration rate (eGFR) annually 1, 2
• Obtain urine albumin-to-creatinine ratio (UACR) annually to identify patients at risk for renal dysfunction and high cardiovascular risk 1, 2
• Microalbuminuria and macroalbuminuria are independent cardiovascular risk factors in diabetes 3

Cardiac Biomarkers for Heart Failure Risk

• Measure BNP or NT-proBNP in patients with diabetes to identify those at risk for heart failure development, progression, and mortality 3, 1
• This is particularly important given that heart failure and chronic kidney disease are the most frequent first cardiovascular disease manifestations in diabetes 3
• Elevated natriuretic peptides identify stage A or B heart failure (asymptomatic but at risk) and guide intensification of risk factor management 3

Additional Risk Profiling

• Complete the cardiovascular risk profile with full blood count, thyroid function tests, liver function tests, and high-sensitivity C-reactive protein (hs-CRP) 1
• In patients with diabetes aged ≥65 years, or with microvascular disease, foot complications, or diabetes duration ≥10 years, screen for peripheral artery disease with ankle-brachial index 1

Cardiovascular Risk Stratification

Coronary Artery Calcium Scoring: The Superior Risk Assessment Tool

• In adults with diabetes ≥40 years of age, coronary artery calcium (CAC) scoring is the preferred imaging test for cardiovascular risk assessment 2, 4
• CAC scoring is consistently superior to both the Framingham Risk Score and UK Prospective Diabetes Study (UKPDS) risk engine in predicting cardiovascular events in diabetic populations 2, 4
• A CAC score of 0 is associated with survival rates similar to non-diabetics with no coronary calcium 2, 4
• 46-60% of asymptomatic diabetic patients have coronary artery calcification despite normal ECGs, highlighting the inadequacy of traditional clinical assessment alone 2

What NOT to Do: Avoiding Unnecessary Cardiac Testing

• Do not perform routine screening for coronary artery disease with stress testing or coronary angiography in asymptomatic diabetic patients, as it does not improve outcomes when risk factors are treated 3, 2
• A randomized trial demonstrated no clinical benefit to routine screening of asymptomatic patients with type 2 diabetes and normal ECGs—despite abnormal myocardial perfusion imaging in more than one in five patients, cardiac outcomes were essentially equal (and very low) in screened versus unscreened patients 3
• Indiscriminate screening is not cost-effective, and high-risk patients should already be receiving intensive medical therapy 3

When Cardiac Testing IS Indicated

• Reserve advanced cardiac testing for patients with typical or atypical cardiac symptoms AND/OR an abnormal resting electrocardiogram 3
• For symptomatic patients, use exercise ECG testing with or without echocardiography as the initial test 3
• In patients with resting ECG abnormalities (e.g., left bundle branch block or ST-T abnormalities) or inability to exercise, use pharmacologic stress echocardiography or nuclear imaging 3

Screening Frequency and Follow-Up

• Assess cardiovascular risk factors at least annually in all patients with diabetes 3, 1
• This includes annual measurement of lipids, glucose metabolism parameters (HbA1c and fasting glucose), blood pressure, and renal function 3, 1
• Patients with prediabetes (impaired glucose tolerance or impaired fasting glucose) should be screened at 1- to 2-year intervals for development of diabetes 5

Common Pitfalls to Avoid

• Do not rely solely on traditional risk scores (Framingham, UKPDS) when CAC scoring is available, as these scores consistently underperform in diabetic populations 2, 4
• Do not assume that normal resting ECG excludes significant coronary disease—nearly half of asymptomatic diabetic patients have coronary calcification despite normal ECGs 2
• Do not proceed to invasive testing without first obtaining appropriate non-invasive risk stratification 3
• Do not forget to measure lipoprotein(a) at least once—it remains stable over time and independently predicts cardiovascular risk 1, 2