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org Cardiovascular Disease and Risk Management S83

unclear what, if any, effect that nding MI may reverse over time, adding to
or symptoms of associated vascular
has on the required dose of aspirin for the controversy concerning aggressive
disease including carotid bruits, tran-
cardioprotective effects in the patient screening strategies (99). In prospective
sient ischemic attack, stroke, claudi-
with diabetes. Many alternate pathways trials, coronary artery calcium has been
cation, or peripheral arterial disease;
for platelet activation exist that are in- established as an independent predictor
or electrocardiogram abnormalities
dependent of thromboxane A2 and thus of future ASCVD events in patients with
(e.g., Q waves). E
not sensitive to the effects of aspirin diabetes and is superior to both the UK
(91). Aspirin resistance has been de- Treatment Prospective Diabetes Study (UKPDS) risk
scribed in patients with diabetes when c In patients with known atheroscle- engine and the Framingham Risk Score
measured by a variety of ex vivo and rotic cardiovascular disease, use in predicting risk in this population
in vitro methods (platelet aggregometry, aspirin and statin therapy (if not (100102). However, a randomized ob-
measurement of thromboxane B2) (88), contraindicated) A and consider servational trial demonstrated no clini-
but other studies suggest no impairment ACE inhibitor therapy C to reduce cal benet to routine screening of
in aspirin response among patients with the risk of cardiovascular events. asymptomatic patients with type 2 dia-
diabetes (92). A recent trial suggested c In patients with prior myocardial betes and normal ECGs (103). Despite
that more frequent dosing regimens of infarction, b-blockers should be abnormal myocardial perfusion imaging
aspirin may reduce platelet reactivity in continued for at least 2 years after in more than one in ve patients, cardiac
individuals with diabetes (93); however, the event. B outcomes were essentially equal (and
these observations alone are insuf- c In patients with symptomatic very low) in screened versus unscreened
cient to empirically recommend that heart failure, thiazolidinedione patients. Accordingly, indiscriminate
higher doses of aspirin be used in this treatment should not be used. A screening is not considered cost-effective.
group at this time. It appears that 75 c In patients with type 2 diabetes Studies have found that a risk factor
162 mg/day is optimal. with stable congestive heart failure, based approach to the initial diagnostic
metformin may be used if estimated evaluation and subsequent follow-up for
Indications for P2Y12 Use
glomerular ltration remains .30 coronary artery disease fails to identify
A P2Y12 receptor antagonist in combi-
mL/min but should be avoided in un- which patients with type 2 diabetes will
nation with aspirin should be used for at
stable or hospitalized patients with have silent ischemia on screening tests
least 1 year in patients following an ACS
congestive heart failure. B (104,105). Any benet of newer noninva-
and may have benets beyond this
sive coronary artery disease screening
period. Evidence supports use of either
Cardiac Testing methods, such as computed tomography
ticagrelor or clopidogrel if no percuta-
Candidates for advanced or invasive car- and computed tomography angiography,
neous coronary intervention was per-
diac testing include those with 1) typical to identify patient subgroups for different
formed and clopidogrel, ticagrelor, or
or atypical cardiac symptoms and 2) an treatment strategies remains unproven.
prasugrel if a percutaneous coronary
abnormal resting electrocardiogram Although asymptomatic patients with
intervention was performed (94). In pa-
(ECG). Exercise ECG testing without or diabetes with higher coronary disease
tients with diabetes and prior MI (13
with echocardiography may be used as burden have more future cardiac events
years before), adding ticagrelor to as-
the initial test. In adults with diabetes (100,106,107), the role of these tests be-
pirin signicantly reduces the risk of
$40 years of age, measurement of cor- yond risk stratication is not clear. Their
recurrent ischemic events including car-
onary artery calcium is also reason- routine use leads to radiation exposure
diovascular and coronary heart disease
able for cardiovascular risk assessment. and may result in unnecessary invasive
death (95). More studies are needed to
Pharmacologic stress echocardiography testing such as coronary angiography
investigate the longer-term benets of
or nuclear imaging should be considered and revascularization procedures. The ul-
these therapies after ACS among pa-
in individuals with diabetes in whom timate balance of benet, cost, and risks
tients with diabetes.
resting ECG abnormalities preclude ex- of such an approach in asymptomatic pa-
ercise stress testing (e.g., left bundle tients remains controversial, particularly
branch block or ST-T abnormalities). In in the modern setting of aggressive
Recommendations addition, individuals who require stress ASCVD risk factor control.
Screening testing and are unable to exercise
should undergo pharmacologic stress Lifestyle and Pharmacologic
c In asymptomatic patients, routine
echocardiography or nuclear imaging. Interventions
screening for coronary artery dis-
Intensive lifestyle intervention focusing
ease is not recommended as it
Screening Asymptomatic Patients on weight loss through decreased calo-
does not improve outcomes as
The screening of asymptomatic pa- ric intake and increased physical activity
long as atherosclerotic cardiovascu-
tients with high ASCVD risk is not rec- as performed in the Action for Health in
lar disease risk factors are treated. A
ommended (96), in part because these Diabetes (Look AHEAD) trial may be con-
c Consider investigations for coro-
high-risk patients should already be re- sidered for improving glucose control,
nary artery disease in the presence
ceiving intensive medical therapydan tness, and some ASCVD risk factors
of any of the following: atypical
approach that provides similar benet (108). Patients at increased ASCVD risk
cardiac symptoms (e.g., unexplained
as invasive revascularization (97,98). should receive aspirin and a statin and
dyspnea, chest discomfort); signs
There is also some evidence that silent ACE inhibitor or ARB therapy if the