[Cardiac imaging in (asymptomatic) diabetic patients]

Coronary artery disease (CAD) plays an important role in diabetic patients because they have a very high cardiovascular mortality risk. Therefore the question arises if all diabetic patients should be screened for CAD. In patients with (a)typical angina or anginal equivalents (e.g. shortness of breath) an extended CAD evaluation is indicated. Unselected screening in diabetic patients, however, does not seem to make sense as the only large prospective randomized study in this field did not demonstrate a survival benefit in the screened patient population. It is noteworthy that preoperative risk stratification deserves special consideration in diabetic patients. If screening is considered there is the anatomic approach (calcium score, non-invasive coronary angiography) or the functional approach (stress testing, ischemia evaluation). In diabetic patients who in general should already have all the medication with respect to coronary prevention, functional rather than anatomic testing makes sense because revascularization can be considered in patients with extensive ischemia. In contrast, anatomic testing if positive would only be confirming that a medical preventive strategy is necessary. On the other hand a normal anatomic test has a very high negative predictive value. Therefore, CAD evaluation should follow an individual patient tailored approach as long as evidence-based guidelines are lacking.