Identifying which patients with diabetes should be tested for the presence of coronary artery disease--the importance of baseline electrocardiogram and exercise testing.

Numerous studies have reported that diabetic patients should not always be considered to be coronary artery disease (CAD)-equivalent as was previously suggested. Exercise testing is widely available at a relatively low cost, and even among patients in whom the diagnosis of CAD is highly probable on the basis of age, sex, description of chest pain and history of prior myocardial infarction, exercise testing is often a clinical requirement for risk or prognosis assessment to determine the need for possible coronary angiography or revascularization. Nevertheless, because of either the presence of atypical symptoms or the absence of symptoms often encountered, the screening approach may differ in patients with diabetes mellitus. Because CAD is the major cause of mortality in patients with diabetes, its early detection is important to improve medical interventions and outcomes. This is critical because the available evidence suggests that occult CAD is common among asymptomatic patients with diabetes. Therefore, noninvasive testing for asymptomatic CAD may be helpful for the identification of diabetic patients with severe coronary obstruction in whom revascularization therapy may be considered the first manifestation of silent CAD in patients with diabetes is a fatal cardiac event in approximately one-half of the patients. The present paper reviews some clinical markers that may be helpful to the clinician to increase the yield of finding significant occult CAD while screening patients with diabetes.