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World J Diabetes. May 15, 2015; 6(4): 634-641
Published online May 15, 2015. doi: 10.4239/wjd.v6.i4.634
Assessment of cardiovascular risk in diabetes: Risk scores and provocative testing
Teresa Lam, Kharis Burns, Mark Dennis, N Wah Cheung, Jenny E Gunton
Teresa Lam, Kharis Burns, N Wah Cheung, Jenny E Gunton, Department of Diabetes and Endocrinology, Westmead Hospital, Sydney 2145, Australia
Kharis Burns, Mark Dennis, N Wah Cheung, Jenny E Gunton, Sydney Medical School, the University of Sydney, Sydney NSW 2006, Australia
Mark Dennis, Department of Cardiology, Royal Prince Alfred Hospital, Sydney 2050, Australia
Jenny E Gunton, Faculty of Medicine, Westmead Hospital, University of Sydney, Sydney 2145, Australia
Jenny E Gunton, St Vincent’s Clinical School, University of New South Wales, Sydney 2010, Australia
Jenny E Gunton, Diabetes and Transcription Factors Group, Garvan Institute of Medical Research, Sydney NSW 2010, Australia
Author contributions: All authors contributed to this manuscript.
Conflict-of-interest: The authors wish to declare they have no conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jenny E Gunton, Professor, Faculty of Medicine, Westmead Hospital, University of Sydney, Room 2040, Clinical Sciences Corridor, Sydney NSW 2145, Australia. j.gunton@garvan.org.au
Telephone: +61-2-98458089 Fax: +61-2-92958404
Received: October 24, 2014
Peer-review started: October 28, 2014
First decision: December 12, 2014
Revised: January 30, 2015
Accepted: February 10, 2015
Article in press: February 12, 2015
Published online: May 15, 2015
Processing time: 203 Days and 7.9 Hours
Abstract

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among patients with diabetes mellitus, who have a risk of cardiovascular mortality two to four times that of people without diabetes. An individualised approach to cardiovascular risk estimation and management is needed. Over the past decades, many risk scores have been developed to predict CVD. However, few have been externally validated in a diabetic population and limited studies have examined the impact of applying a prediction model in clinical practice. Currently, guidelines are focused on testing for CVD in symptomatic patients. Atypical symptoms or silent ischemia are more common in the diabetic population, and with additional markers of vascular disease such as erectile dysfunction and autonomic neuropathy, these guidelines can be difficult to interpret. We propose an algorithm incorporating cardiovascular risk scores in combination with typical and atypical signs and symptoms to alert clinicians to consider further investigation with provocative testing. The modalities for investigation of CVD are discussed.

Keywords: Diabetes; Cardiovascular risk; Risk scores; Provocative testing; Silent ischaemia; Atypical symptoms

Core tip: Current guidelines focus on testing for cardiovascular disease in symptomatic patients. However, patients with diabetes often present with atypical features of underlying vascular disease. An individualised approach to cardiovascular risk estimation and management is needed in patients with diabetes. We propose an algorithm incorporating cardiovascular risk scores in combination with typical and atypical signs and symptoms to alert clinicians to consider further investigation with provocative testing. The modalities for investigation of cardiovascular disease are discussed.